Tuesday, August 06, 2013

1768: Dr. Phillip Stern writes book for asthmatics

So it's the year 1767 and you have asthma.  For the price of just one schilling you can purchase a copy of Dr. Phillip Stern's book called, "Medical advice to the consumptive and asthmatic people of England."  It's one of the first books ever written specifically for you, the patient.

Now there's a catch here of course.  He apparently admits to writing the book directly to the patient because he apparently had a falling out with his fellow physicians.  Perhaps it was because his ideas are rejected by the medical profession.  Or perhaps it was because he rejects the methods of the medical community and postulates his own.

Many historians presume his ideas were rejected by the medical community specifically because he wrote his book to the public, and not to physicians (which was the norm back then).  And, to be honest, Dr. Stern does use some harsh wording when referring to his physician contemporaries.

Regardless, he provides a brief anatomical review of the heart, vessels, diaphragm and respiratory system.  He describes how the lungs are "divided into two principle lobes which are inclosed in two distinct bags, formed by a membrane called the pleura; so that the right and the left lobe of the lungs have not the least communication."

Now this separation of the two lungs is important, because when a portion of one lung becomes diseased or dies, perhaps due to pneumonia or consumption, the patient can continue to live.  He writes:
"But here it may naturally be asked, how it happens, when a part of an organ, so indispensably necessary to life, is destroyed, that the patient does not immediately die.  I answer that Nature, in this instance, has been particularly kind to us; for the two lobes of the lungs, have no communication, are not immediately affected by each other's diseases; besides, every minute branch of the same lobe is so contrived, as to perform its office independent of the rest; therefore every single vessel continues to receive and return its portion of air, till it be actually destroyed." (1, page 11)
So the lungs are resilient to disease, and parts of them can continue to work regardless of the diseased parts.  This is good when it comes to diseases like pneumonia or consumption which can close off portions of the lungs to the reception of air.

The majority of Sterns book describes the disease consumption, his theories as to the pathology of the disease and his perceived remedies.  It isn't until we get to page 33 that we learn about asthma, "that disorder, the chief symptom of which is difficulty of breathing.  It is either continued or by fits."  (1, page 33)

Regarding the cause he writes: "Now, though the cause of the disease is frequently in the lungs, yet it is sometimes owing to a morbid affection of some of the other organs of respiration, as the diaphragm, the intercostal muscles, or the windpipe, or some of the neighboring viscera."

Pretty much that's all he offers us about our disease.  He then jumps right into his only remedy, his own balsamic medicines, the same medicines he recommends for consumptives.  He explains the first remedy to asthmatics is bleeding, yet after that he recommends balsamics to be provided by the inhaler he invented.

Here we must pay attention to his explanation:
"Well; but then we administer a quantity of saccharine, oily and mucilaginous medicine, in the form of an emulsion, intending, no doubt, thereby to sheathe and obtund the acrimony, which causes the irritation in the lungs.  The intention is certainly laudable; but it happens unfortunately that these balsamics go down, not into the lungs, but into the stomach, where they immediately go through such a change, as to carry but little of their balsamic qualities even into the intestines, where they are still farther mixed and adulterated, particularly by the addition of a certain quantity of bile, immediately on quitting the stomach."  (1, page 14)
He further explains that medicine can be taken by the mouth, pass through the stomach, gather access to the vessels of the body, and effect the heart, and even act as poisons in this way.  However, he notes the following:
"Now it must be remembered that the seat of the disorder which, by their healing medicines, we are endeavouring to cure is not in the blood vessels, but in the air vessels of the lungs; and that these air vessels have no communication with the arteries, except by means of tubes or pores so extremely small, as not to admit the red globules of the blood; consequently the constituent particles of our medicine must be smaller than these, otherwise no part of it can possibly be thus applied to the part injured." (1, page 15-16)
He therefore concludes that "the only possible way of applying medicine directly to the lungs, is through the windpipe."  (1, page 16)

Later he explains to the asthmatic:
"If... these balsamics, taken into the stomach, can do nothing toward the cure of consumption, how much less likely are they to relieve an asthmatic patient?  For if they could ever be applied immediately to the part affected, they possess no one virtue that might authorize such expectation." (1, page 34)
Here he makes an observation that was probably first made by ancient people, as even the ancient Egyptians, and Ancient Indians, observed that medicine to improve affections of the airway often works better when inhaled.  And that is exactly what Stern is prescribing here: the inhalation of his balsamic powders with an inhaler that he invented.

He writes that "when the cause of the asthma is spasmotic contraction of the lungs, or windpipe, which is very frequently the case, especially when the disease returns by fits, I then expect considerable advantage from the antispasmotic powders of this vapour; and when in a continuous difficulty of breathing, the cause of the disorder is an infarction of the lungs from viscid mucus, my hopes are then build on the attenuating power of the vapour exhibited in the manner I recommend. Let those who are capable of reasoning, judge whether my expectations are well founded." (1, page 34)

The medicine may be inhaled through the use of any teapot, although for consumption (or asthma) "a more copious application is necessary.  For this purpose I have contrived a simple machine, by means of which a much greater quantity of the balsamic effluvium is received into the lungs... It holds about a pint.  Half a pint of boiling water must be poured in, and the medicine immediately dropped into the water.  The head being then fixed upon it, the patient applies his mouth to the pipe, and thus draws in the steam with his breath, removing the pipe from his lips at every expiration.  The vessel is made of pewter.  Those who are acquainted with the nature of evaporation will not be at a loss to account for the conic form of the vessel."

Note he did not use the word 'inhaler.'  (3, page 54)  In reality his invention may be the first inhaler. However, perhaps because his ideas were rejected by the medical community, his inhaler never caught on.  He also didn't use the word inhaler. So perhaps for this reason it wasn't his, but Dr. Mudge's inhaler invented a decade later, that is often given credit as the first inhaler.  Yet for the first time, we will give Dr. Stern full credit here:  Dr. Phillip Stern invented the first marketable inhaler.

He also recommends inhaling the balsamic vapours using his contraption of which he does not refer to as an inhaler, as such a word will be used by one of his contemporaries.  (2) 

The medicine:  Dr. Sterns Balsamic Vapour or Dr. Sterns Balsamic Ether

Ingredients:  Dr. Sterns will not reveal his ingredients, although we might assume he enters into it some or all of the following, which are mentioned in his book:
  •  Antiseptic powder
  •  Ether
  •  Balsams (of Gilead, Copaiba, Peru, Tolu, and Canada)
  •  Dry Balsams (Benjoine, Storax, Labdanum, Myrrh, Mastich)
  •  Terpentines
  •  Antispasmotics
  •  Opium
Research:  Dr. Sterns did a test using the vessel and his balsamic ether on himself, and it worked.

Indications:  Common colds, hoarseness, tuberculosis, asthma, etc.

Cost:  Six Schillings and sixpence per bottle

Where:  Various shops

Directions:  "I usually drop 30-40 drops into half a pint of boiling water immediately after it is taken from the fire, ordering the patient to hold his mouth over the vessel, so as to draw in with his breath as much as possible of the vapour, continuing the operation as long as the steam will rise.  I then order him to drink the water as soon as it is cold enough for that purpose: for, though I depend  entirely on the vapour for the cure of the lungs, yet, as of all the juices in the body may in some degree affected by the matter absorbed from the lungs, this balsamic water, received into the stomach, will be of some advantage." (1, page 24)

Or...

"30 or 40 drops to be dropped into a quart of boiling water, and the vessel to be placed near the bed of the patient, and to be repeated three or four times a day; or the water to be kept boiling over a lamp, in any part of the room, until it is entirely evaporated, if the disorder be of a very putrid nature, and especially in the small pox."  This technique may also be beneficial in sore throats "whether inflammatory or putrid."

Frequency:  The Stern's "Inhaler" may be used by adding half a pint of water, boiling it (2), "and by holding my head over a common pint vessel, keeping my mouth generally shut, that the steam might pass through my nose, and repeating the operation several times a day, for two or three days." (1, page 24)

When to use:  Use during an attack of asthma, although it is best to "prevent a disorder than to cure it, and as colds do no injury to the lungs, except in their remote effects, I thought it rational to suppose, if immediately after taking cold, I could dilute or obtund the acrimony of the humour that irritates and inflames the lungs, I should probably prevent the bad consequences of obstructed perspiration, at least as far as it concerned the lungs." (1, page 34)

References:
  1. Stern, Phillip, "Medical advice to the consumptive and asthmatic people of England," 1870, London  (1st edition was 1767)
  2. Sanders, Mark, "Dr. Stern's Inhaler," Inhalatorium.com,  http://inhalatorium.com/page133.html.  Mr. Sanders also provided us with permission to use the picture on this page.  Please check out the Inhalatorium to see for yourself the history of aerosolized therapy.  You may also check out a slideshow presentation by Mr. Sanders,    "The Innovators of Inhalation," http://www.ddl-conference.org.uk/files/DDL20presentations/19.Sanders.pdf
  3. Smyth, Hugh D.C, Anthony J. Hickey, "Controlled Pulmonary Drug Delivery," 2100, Springer New York Dordrecht Heidelberg London

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