Tuesday, May 06, 2014

1820-1910: Henoch links pediatric bronchitis with asthma

Eduard Heinrich Henoch was a German physician who made significant contributions to the study of pediatrics, and through his lectures and books, contributed wisdom to the knowledge of pediatric diseases, including a theory of the contribution of asthma in catarrhal pneumonia.  (1, page 673)

A few definitions are required here.  

Catarrh:  Inflammation of the respiratory tract.  Catarrh that occurs between the trachea and large and medium bronchi.  According to Henoch it's among the "commenest diseases of childhood."  Contributing factors may be cold, moist air, cold bath, taking child out in bad weather, rickets, and the appearance of the first teeth. It sometimes occurs after scarlet fever or small pocks.  Symptoms are hacking cough, stuffiness, and rattling in the chest. A parent may also hear moist rhales due to secretions, and is often a dry noise like that of croup (stidor).  The appearance of the child may cause parental anxiety. Sonorous rhonchi may also be heard (what we now call rhonchi, or the sound of air being forced through secretions.) Few medicines benefit it, and it usually goes away within a month, although can become chronic.  Signs of serious respiratory compromise is head bobbing with each breath, and retractions and grunting occur.  The observation of catarrh and the above symptoms may lead to a diagnosis of bronchitis, or broncho-pneumonia.

Bronchitis:  The main difference between adult and pediatric bronchitis is the greater tendency for it to reach the bronchi. Essentially, bronchitis is when the the mucus membranes of the bronchi are red and swollen, resulting in a cough.  Other possible symptoms are noted above. (2, page 379-380)

Broncho-pneumonia (catarrhal pneumonia):  It is generally caused by affections of bronchitis.  When catarrh or bronchitis affects the lung tissue.  It is difficult to diagnose with certainty, although with more significant symptoms it cannot be excluded. Symptom of this may be severe respiratory compromise, and thick, yellow secretions.  Secretions may cause parts of the lungs to be blocked off, causing atelectasis, emphysema, and these interfere with the process of oxygenation. (2, page 383)

Acute Bronchial Catarrh (Recurrent Bronchitis):  Episodes of catarrh that present much like asthma in adults, and sometimes presents as false croup (creating a harsh inspiratory noise, or stridor).  They may occur yearly, or "every slight chill or cold in the head."  It presents with dyspnea.  Sometimes this results from persistent chronic bronchial catarrh. (2, page 393)

Reflex Spasm (asthma dyspepticum):  A spasm that is secondary to irritation of the stomach or dyspepsia, a.k.a. indigestion, perhaps due to eating too much, or eating the wrong foods.  This is generally caused by a reflex through the pneumogastric, which was believed to cause spasm of the lungs via stomach irritation (3, page 198-199).  

Henoch suspects a link between broncho-pneumonia and asthma:  
Still, I consider it possible that a spas tic contraction of the bronchial muscles as in bronchial asthma may have something to do with this condition. I have repeatedly seen children who were never quite free from bronchial catarrh but always had sibilant rhonchi here and there, especially audible over the back. From time to time, especially following a cold in the head, there arose very suddenly a violent asthmatic attack with slight cyanosis of the face, without the larynx, however, being affected—i.e. without hoarseness or croupy inspiration. Unfortunately there was no sputum at all. All over the chest we heard sibilant rhonchi and very weak breathing. This alarming (but non-febrile) attack lasted occasionally scarcely half an hour or an hour and then disappeared as by magic, being replaced by the previously existing catarrh. The short duration as well as the sudden onset and equally rapid disappearance of the attack is in favour of a reflex spasm of the bronchi being present, which many specialists have recently described as depending on states of irritation of the nasal mucous membrane.
Treatment:    (2, pages 395-399)
  1. Simple catarrh usually resolves itself spontaneously in a week or two
  2. Ipacacuanha is a good remedy (it makes the person vomit.  This must have been a remedy to treat reflex spasm).  Other physicians have also noted a good vomit to improve breathing and end an attack of bronchitis or asthma.  Henoch does not believe it ends catarrh, although "I do not deny its soothing influence on the cough."  A good sign it's indicated is diarrhea. 
  3. Ipacacuanha with calomel is recommended when condition presents with constipation and fever.
  4. He no longer recommends leeches to the thorax, an old remedy.  This change was made because, as Henoch writes, "the loss of blood is considered too weakening and dangerous."
  5. Blood letting: Of this he writes: " Former experiences1 have shown me that local blood-letting in moderation has by no means the bad results (anaemia, collapse) which the modern timorous school of practice imputes to it: and I cannot maintain that my results in bronchopneumonia have become more successful since I banished bloodletting entirely from my practice."
  6. Antiphlogistics:  This is medicine to reduce inflammation.  Henoch notes surprise in the success of this line of treatment.
  7. Wet or Dry cupping: This is the application of 4-8 cups, according to age, to the skin.  These cups are  are applied to create suction to improve blood flow to induce healing.  This he recommended in place of bleeding.  He prefers dry cups to wet cups. 
  8. Wet compresses: Applied to chest from the beginning of illness.  Generally, a wet napkin or towel will do.  
  9. Emetics:  He recommends tartar emetic.  Stop when diarhhea and vomiting occurs after each dose.  
  10. Aromatic spirit of amonia to increase coughing when you hear rhales indicative of increased secretions in the chest to induce expectoration (spitting up of secretions). 
  11. Mustard plasters over the sternum and back, and small fly blisters on the thorax:  Recommended to increase expectoration.  Should both be done at same time
  12. Milk, beef tea, wine (Sherry, tokay, and port):  Should be given alternatively to maintain strength, and may be given in order to help expectoration.
  13. Camphor and Benzoic Acid: If the above expectorants don't work, these may be tried. 
  14. Warm baths:  May also induce expectoration. 
  15. Visit to sea side:  Generally, visit to sea side in the North Sea.  This is done for recurrent bronchitis (and this is similar to hay fever vacations).  Sea air is not recommended as treatment for a "fresh attack," although it makes a good after treatment (prevents recurring attacks).  
  16. Compressed air:  He has found no good results from it, although notes he has minimal experience.
The writings and lectures of Henoch represent the impact and influence of science on the practice of medicine, as is evident by the practical observation that bronchitis is similar to asthma, and that such irrational practices as bleeding and leeching may do more harm than good.  

References:
  1. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1921, Philadelphia and London, W.B. Saunders Company
  2. Henoch, Eduard Heinrich, "Lectures on children's diseases: a handbook for practitioners and students," translated by John Thomson, 1889, London, The New Sydenham Society
  3. Henoch, Eduard Heinrich, "Lectures on diseases of children; a handbook for physicians and students," 1882, New York, William Wood and Company



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