1800-1900: Race to define asthma is on

The rest of the 19th century consists of one physician after another coming up with his theory as to the cause of asthma.  Each is convinced he is right, and each offers the best proof he can.  Historians can argue whether this slowed down search for better asthma wisdom, or actually sped it up.

Franz Daniel Reisseissen is a German physician who studies the lungs, and he concludes that "there is another apparatus appointed for contracting the bronchi, which consists of transverse muscular fibres.  As far as the cartilaginous rows extend, these fibres are inserted...." (7)

In other words, according to "The Cyclopaedia of practical medicine" (edited by John Floyer in 1833, volume 1, page 186), Reissiessen proves muscle fibres wrap around the air passages of the lungs almost all the way to the alveoli.  His writings are published in Berlin in 1822.

It isn't until "the paper by Francis Hopkins Ramadge (1835, you can view his book here*.) and the prize essays of Bergson and Lefevre (1836) that asthma is really regarded as a neurosis of the respiratory organs," according to Whitaker. (8)

Barry E Brenner, in "Emergency Asthma" (edited by Barry E. Brenner, 1998, page 7) wrote that Ramadge, described food as an asthma trigger, recommends moving from the city to country,  and of asthma being mostly a nocturnal disease. He discourages use of opiates because they impede respirations that are already impeded. He mainly recommends strammonium because it "produces a grateful forgetfulness and a balmy oblivion like opiates." (9)

J.B. Berkart in his 1878 book "On Asthma:  It's Pathology and Treatment" (volume I, page 23) described that Lefevre observed his own asthma and that of a friend and concluded asthma could only be caused by bronchospasm.  Yet he (Lefevre) believed this bronchospasm was caused by the mind.  (10)

Berkart wrote that "in essence of the disease he (Lefevre) considered to be an increased irritability of the nerves of the lungs, in consequence of which the slightest irritation applies to the bronchial surface induced spasm of the bronchial tubes." (10)

Whitaker wrote that the view of asthma as a nervous disease was further established by "Romberg (1841) who based his conception of the disease as a spasmus bronchialis, upon the discovery by Reiseissen (1808) of muscular tissue in the finer bronchial tubes, and the contraction of these tubes under galvanization of the lungs by Charles J.B. Williams (1840), and irritation of the vagus (nerve) by Dr. Francois Achille Longet (1842)."

According to William Pepper and Louis Star, "It was ascertained by Williams that by irritating the lung he could cause contraction of these fibres, and Longet subsequently proved that the same effect could be produced by galvanizing the pneumogastric nerve."  (11)

Berkart wrote that Williams performed experiments that proved without a doubt "that mechanical and electrical stimuli do produce contraction of the air-tubes. Thus the theory of a bronchial spasm obtained the support of experimental physiology. And even those who until then wavered in their opinions as to the possibility of such a spasm saw now no reason for doubting, but readily accepted that doctrine."

Williams must have agreed with Laennec and Berkart that asthma was an abused term.  Whitaker noted that in 1768 there were 17 different types of asthma (as described by Savage) and in 1822 this was reduced to 11 (by Richter). This was confusing.  Williams wanted to simplify the definition of asthma.

Williams became the first to break asthma into two types: spasmodic and paralytic. Berkart wrote that as of the writing of his (Berhart's) book, the two terms described by Williams were the ones accepted by most experts.  However, other doctors would continue to reclassify asthma to their own content and amusement.

Yet while his research led Williams in the correct direction, along came Dr. Francois Achille Longet who, in 1842, did experiments of his own only to prove that, as Berkart wrote (page 27) that "irritation of the pneumogastric nerve always produced spasmodic contraction of the bronchi, whereas section of the nerve led to emphysema, which was described as distention of the air vesicles (what we now call air trapping)."  (12)

Longet also believed bronchospasm and emphysema (air trapping) were both parts of asthma. If we could hop into our virtual time machine we could tell him he was right. We could tell him that spasming of the bronchiole muscles (which he referred to as fibres) caused air to become trapped in the alveoli. This we know is air trapping, or what what was grouped back then under the term emphysema.

If we could do that we could have put an end to the whirlwind of theories that I think delayed progress that may have resulted in beta adrenergic medicine to relax these smooth muscles long before they were finally discovered in 1900. We could have stopped the whirlwind of false steps and experiments that lead to poppycock theories such as the nervous theory of asthma.

So in 1840 Charles Williams -- who was ultimately the same person to come up with the term lub dub to describe the beating of the two chambers of the heart -- became the first to prove that certain irritants cause contraction of the muscular fibres that Reisseissen proved wrap around the air passages in the lungs.

In 1848 histologist Rudolph A. von Killiker confirmed the works of Williams and Reisseissen when he isolated smooth muscles of the lungs, according to John Daintith in his book "Biographical encyclopedia of scientists."  (13)

This essentially proved Cullen wrong, that the muscle was not just a continuation of a nerve.  Yet since nerves still connected to muscles, van Killiker's discovery was unable to stop the fallacy of the nervous theory of asthma.

The thing to note about most of these experts is that even while they believed in the bronchospasm theory of asthma, they continued to believe it the nervouse theory of asthma, and their experiments prooved the two co-existed  -- or so they thought.

References:

1. Pepper, William,  Louis Star, "A System of Practical Medicine," Volume 3, page 184
2. Berkart, J.B., "On Asthma: It's pathology and treatment," 1878, London,  Chapter II, "History of Asthma," page 12
3. Bree, Robert, "A Practical Inquiry into Disordered Respiration, distinguishing the Species of Convulsive Asthma, their Causes, and Indications of Cure, London, 1810.  I could not find the 1790 edition online, yet this one serves our purpose.
4. Schmiegelow, Ernest, "Asthma, considered specially in relation to nasal disease," 1890, London, page 4 
5. Jackson, Mark, "Asthma: The biography," 2009, London, pages 86-88 (If you're interested in a good asthma history book, this is it.)
6.  Bryan, Jenny, "Asthma," 2008, page 8
7. Floyer, John, ed., "The Cyclopaedia of practical medicine," 1833, volume 1, page 186
8. Whitaker, James Thomas, "The theory and practice of medicine," 1893
9. Brenner, Barry E, ed, "Emergency Asthma" 1998, page 7 (chapter one is a history of asthma written by Brenner)
10. Berkart, J.B.,"On Asthma:  It's Pathology and Treatment, 18xx, volume I, page 23 (Berkart started his book with a good history of asthma up to his time.  I base much of this post on his thorough asthma history.)
11. Pepper, op cit, page 194
12. Berkart, op cit, page 27
13. Daintith, John, "Biographical encyclopedia of scientists."

Other readings:

• Ramadge, Francis Hopkins, "Asthma, its species and comications, 1835, London
• Duchenne, Guillaume Benjamin, "Selections from the works of Dr. Duchenne (de Boluogne)," 1883, London

Note:  This post updated on 2/14/13 and republished under a different url 

1800-1900: Spasmotic and nervous theories win the day

Jean Antoine Villemin became famous as the person to prove that tuberculosis was contagious after rabbits he injected with tuberculosis from humans contracted the disease.

In 1860 Jean Antoine Villemin tried to disprove the nervous theory with his own scientific experiments, yet once again the nervous theories were so popular Villemin's common sense approach was ignored.

Villemin actually came up with a theory in a circuitous way describing what we now call air trapping.

Deprived of "nutrition," Berkman wrote in describing Villemin's theory, "the air vesicles (alveoli) became impaired, they were unable to efficiently perform expiration.  At the same time respiratory surface was reduced, and the blood accumulated in the bronchi (inflammation) to such an extent as to convert their mucous membrane into a kind of erectile tissue.

"This condition gave rise to no symptoms," Berkart continued, "either subjective or objective."  The only time symptoms occurred

Villeman's theory here might be a little off, yet our time traveler would benefit history if he could somehow convince Villemin not to give up trying to convince other experts that they were wrong and he was sort of on the right track.  Your time traveler's attempts might prevent the 130 year delay.

So this is how it went throughout most of the 19th century.  Is asthma caused by the vagus?  Is it spasmotic?  Is it a result of spasms of the diaphragm?  Is it a result of paralysis of the air passages?  Is asthma both spasmotic and emphysema?

The debate was pretty much ended when Henry Hyde Salter entered the picture.  Salter would become the pre-eminent asthma expert of the second half of the 19th century.  In fact, he was so famous he was even consulted to be the asthma doctor for a boy who would one day become President of the United States (I'll write about that in the coming weeks).

Salter published the original version of "On Asthma:  It's Pathology and Treatment," in 1864 (Salter's book was published prior to Berkarts).  Based on his own experience with asthma, and observations of his own patients, he accurately described the asthma patient during an asthma attack.

He wrote that he saw enough evidence to believe in the spasmotic theory of asthma, yet he also believed that bronchospasms were caused by nervous stimulation.  He also believed asthma was an inflammatory disease and wrote about asthma as a hereditary disorder.

Salter believed some exciting factor (like dust or sterss) was recognized by the abdulla oblongotta, and a signal was sent via the pneumogastric nerve to the bronchiole fibres that wrap around the lungs signalling them to constrict.  In this way asthma was a nervous condition.

Salter offered the following examples as proof asthma was started in the brain:

• Many patients feel fine as soon as they enter the doctor's office
• Mental emotion can bring on a paroxysm of asthma
• Mental emotion can resolve a paroxysm of asthma
• Remedies that relax the nervous system resolve asthma, such as tobacco, antispasmodics, and sedatives, nervous depressants. Examples include tobacco, alcohol, morphine, and especially chloroform.

Berkart noted that in 1843 George Hirsh said he (Hirsh) didn't understand how asthma could affect so many boys if it were a nervous disorder. Salter better described this in his book, stating that asthma is a disease that causes the boy to yearn for his mother. It's this yearning that results in an asthma attack.

Thus, it's for this reason Salter justifies using remedies to calm the mind such as smoking cigarettes, alcoholic drinks, formaldehyde, and sedatives. (to see more Salter remedies click here).  Salter didn't deny the convulsive theory of asthma, yet his main focus was on the nervous theory because he believed the mind caused the convulsions or spasms in the lungs.

Pepper and Star explained that by the time the third edition of their book "A System of Practical Medicine" was published in 1885, Williams and Longet's bronchospasm theory of asthma was readily accepted. They wrote that "most modern pathologists have arrived at the conclusion that bronchial asthma is a spasmotic contraction of the middle and finer bronchi dependent on some derangement in the function of the pneumogastric nerve."

Likewise, Whitaker added that "whatever doubt still hung about the contraction of the bronchial tubes themselves would seem to have finally been dissipated by Lazarus (1891), who devised an ingenious apparatus wherewith he could, with the aid of curare and tracheotomy, experiment on animals in life, and whereby he produced the characteristic dyspnea of the disease by irritation of the vagus nerve."

Brenner (page 9) noted that sometime around 1900 Willem Einthoven (the inventor of the EKG) evaluated the bronchospasm theory of asthma and spasming diaphragm theory of asthma and proved the bronchospasm theory.

So based on experiments and personal observation, and with the appraisal of highly rated doctor's like Henry Hyde Salter, the bronchospasm and nervous theory of asthma won the day.  The nervous theory remained popular until it was disproved in the 1950s.  However, it really wasn't until the 1980s that the theory was laid to rest.

The bronchospasm theory of asthma lives on.

Click here for more asthma history.

References:

1. Pepper, William,  Louis Star, "A System of Practical Medicine," Volume 3, page 184
2. Berkart, J.B., "On Asthma: It's pathology and treatment," 1878, London,  Chapter II, "History of Asthma," page 12
3. Bree, Robert, "A Practical Inquiry into Disordered Respiration, distinguishing the Species of Convulsive Asthma, their Causes, and Indications of Cure, London, 1810.  I could not find the 1790 edition online, yet this one serves our purpose.
4. Schmiegelow, Ernest, "Asthma, considered specially in relation to nasal disease," 1890, London, page 4 
5. Jackson, Mark, "Asthma: The biography," 2009, London, pages 86-88 (If you're interested in a good asthma history book, this is it.)
6.  Bryan, Jenny, "Asthma," 2008, page 8
7. Floyer, John, ed., "The Cyclopaedia of practical medicine," 1833, volume 1, page 186
8. Whitaker, James Thomas, "The theory and practice of medicine," 1893
9. Brenner, Barry E, ed, "Emergency Asthma" 1998, page 7 (chapter one is a history of asthma written by Brenner)
10. Berkart, J.B.,"On Asthma:  It's Pathology and Treatment, 18xx, volume I, page 23 (Berkart started his book with a good history of asthma up to his time.  I base much of this post on his thorough asthma history.)
11. Pepper, op cit, page 194
12. Berkart, op cit, page 27
13. Daintith, John, "Biographical encyclopedia of scientists."

Other readings:

• Ramadge, Francis Hopkins, "Asthma, its species and comications, 1835, London
• Duchenne, Guillaume Benjamin, "Selections from the works of Dr. Duchenne (de Boluogne)," 1883, London

1800-1900: Experts aim to prove asthma theories

So here I continue my description through the 19th century in my guide's time machine.  Earlier I described how my guide explained about how experts tried to defend old theories, and then worked to debunk them.  Through the glass walls I see a blur and then the machine seems to come to a stop, and the man we see is...

"It's Jean Baptiste van Helmont," my guide says.  I take a picture with my iPhone hoping it will turn out.  "I apologize I didn't explain this before, but what we are seeing are mere images from the past, not real scenes.  Like vampires, they don't show up on film."

"Oh, I guess I kind of figured that."  Yet I continue to snap pictures, hoping beyond hope to have proof to offer on my blog as I'm writing about this later.  

In a harsh voice, my guide explains "that the nervous theory of asthma is first described in the 17th century by Jean Baptiste van Helmont and Thomas Willis, and in the 18th century by William Cullen.  Most asthma experts in the 19th century believe wholeheartedly that asthma is caused by a nervous response, and the evidence -- so they think -- is overwhelming."

He says, 'Ironically, when Cullen's convulsive theory of asthma is proven, this does nothing to disprove the nervous theory.  In fact, many experts go on to prove that beyond a reason of a doubt the convulsive theory of asthma further proves their nervous theory of asthma."

He continues:  "In 1808 Franz Reisseisen performs experiments that prove muscular fibrers wrap around the air tubes of the lungs, according to Jenny Bryan in her book 'Asthma.'"  (1)  He hands me the book.  "In our day we know these muscular fibres are smooth muscles we call bronchial muscles."  I set the book down on a glass table to my right.

We now see a man, with a bloody apron and knife, standing before a table with a corpse cut about the chest. We can see inside the body, and we can see that this man is looking at the heart and lungs.  "The body I have no idea who that is.  My guess would be a prisoner, although I have no evidence of that.  The doctor, that is a doctor, his name is Dr. Robert Bree.  He's the pre-eminent asthma expert from 1800 through 1850.

"So Mark Jackson explains -- yes, we're back to him again because his review of asthma through my century, the 19th century, is exemplary -- 'that Robert Bree attempts to prove his theories by dissecting the lungs of asthmatics who died of an attack, however this is a problem because asthmatics rarely die.  Bree therefore has to dissect the lungs of people who died of other diseases similar to asthma." (2)

While caressing his cigarette, he looks at me.  "Many people from your era find this hard to understand, but most asthma experts in my day wrote in their respective books that few asthmatics died from asthma.  Surely the condition was a nuisance, yet it killed few.  At least this was true of pure asthma.  If asthma killed, it was because it was accompanied with another disease, like bronchitis, emphysema or pneumonia."

He notes that prominent experts who note this are Henry Hyde Salter and William Henry Osler.  "While low risk of death bodes well for the asthmatic, it doesn't bode well for science."

He lights a match and watches as the flame flickers in a breeze from a vent on the side of his seat.  He says, "Either way, by 1808 Franz Reissesen discovers that the fibres wrap around the air passages of the lungs even to the 'minutest bronchi,' according to Pepper and Starr.  As these fibres contract, the air passages of the lungs become narrower. 

"Rene Leannec's 1816  invention of the stethoscope allows physicians to differentiate the unique sounds of asthma from other diseases.  Like Bree, laennec attempts to compare signs and symptoms of disease during life with what he saw on autopsy.  Laennec assesses patients and comes to conclusions.  He comes to believe in the convulsive theory of asthma, and he also believes catarrh to be the most frequent cause of asthma.

"And,"  He waves the flame out as it nearly singes his finger. "James Thomas Whitaker in his 1893 book, 'The theory and practice of medicine' quotes Leannec as saying: 'Few terms have been so abused in medicine or made to designate such different diseases (than asthma).'  By using his new stethoscope, he aimed to prove asthma is a disease of bronchospasm and nothing more.

"Laennec is the first to use such descriptions as rhales and rhonchi to describe lung sounds heard by auscultation, and the sounds heard during an asthma attack he describes as rhonchi."  He lets the cigarette fall to his lap.

"Rhonchi is later be divided into sibilant and sonorous, with sibilant rhonchi (now called a wheeze) being the sound of air traveling through narrowed airways, and sonorous rhonch (now called rhonchi) being the sound of air traveling through secretion filled airways."

References

1.  Bryan, Jenny, "Asthma," 2008, page 8
2. Jackson, Mark, "Asthma: The biography," 2009, London, pages 86-88 (If you're interested in a good asthma history book, this is it.)

Continue the journey by clicking here.

References:

1. Pepper, William,  Louis Star, "A System of Practical Medicine," Volume 3, page 184
2. Berkart, J.B., "On Asthma: It's pathology and treatment," 1878, London,  Chapter II, "History of Asthma," page 12
3. Bree, Robert, "A Practical Inquiry into Disordered Respiration, distinguishing the Species of Convulsive Asthma, their Causes, and Indications of Cure, London, 1810.  I could not find the 1790 edition online, yet this one serves our purpose.
4. Schmiegelow, Ernest, "Asthma, considered specially in relation to nasal disease," 1890, London, page 4 
5. Jackson, Mark, "Asthma: The biography," 2009, London, pages 86-88 (If you're interested in a good asthma history book, this is it.)
6.  Bryan, Jenny, "Asthma," 2008, page 8
7. Floyer, John, ed., "The Cyclopaedia of practical medicine," 1833, volume 1, page 186
8. Whitaker, James Thomas, "The theory and practice of medicine," 1893
9. Brenner, Barry E, ed, "Emergency Asthma" 1998, page 7 (chapter one is a history of asthma written by Brenner)
10. Berkart, J.B.,"On Asthma:  It's Pathology and Treatment, 18xx, volume I, page 23 (Berkart started his book with a good history of asthma up to his time.  I base much of this post on his thorough asthma history.)
11. Pepper, op cit, page 194
12. Berkart, op cit, page 27
13. Daintith, John, "Biographical encyclopedia of scientists."

Click here for more asthma history.

References:

1. Pepper, William,  Louis Star, "A System of Practical Medicine," Volume 3, page 184
2. Berkart, J.B., "On Asthma: It's pathology and treatment," 1878, London,  Chapter II, "History of Asthma," page 12
3. Bree, Robert, "A Practical Inquiry into Disordered Respiration, distinguishing the Species of Convulsive Asthma, their Causes, and Indications of Cure, London, 1810.  I could not find the 1790 edition online, yet this one serves our purpose.
4. Schmiegelow, Ernest, "Asthma, considered specially in relation to nasal disease," 1890, London, page 4 
5. Jackson, Mark, "Asthma: The biography," 2009, London, pages 86-88 (If you're interested in a good asthma history book, this is it.)
6.  Bryan, Jenny, "Asthma," 2008, page 8
7. Floyer, John, ed., "The Cyclopaedia of practical medicine," 1833, volume 1, page 186
8. Whitaker, James Thomas, "The theory and practice of medicine," 1893
9. Brenner, Barry E, ed, "Emergency Asthma" 1998, page 7 (chapter one is a history of asthma written by Brenner)
10. Berkart, J.B.,"On Asthma:  It's Pathology and Treatment, 18xx, volume I, page 23 (Berkart started his book with a good history of asthma up to his time.  I base much of this post on his thorough asthma history.)
11. Pepper, op cit, page 194
12. Berkart, op cit, page 27
13. Daintith, John, "Biographical encyclopedia of scientists."

Other readings:

• Ramadge, Francis Hopkins, "Asthma, its species and comications, 1835, London
• Duchenne, Guillaume Benjamin, "Selections from the works of Dr. Duchenne (de Boluogne)," 1883, London

1750-1850: Defending old asthma theories

We now leave the comforts of our time machine and find ourselves in a smoke filled office.  Behind a large wooden desk sits a stout, mustached man with black hair falling down over his right eyebrow.  Stuffed in the corner of his mouth is a large cigar.

Our guide says, "This is the famous Dr. Bree.  He wrote a book about asthma in 1797 called "A Practical Inquiry into Disordered Respiration, distinguishing the Species of Convulsive Asthma, their Causes, and Indications of Cure." It would go on to become the most read asthma book of the first half of the 19th century.

"Dr. Bree," our guide continues, as the man we are observing flips the page of a book he appears to be perusing, "was an ardent proponent of the bronchitic theory of asthma, a theory that states asthma is caused by an increase in phlegm in the lungs. In this way, he is one of the last known physicians to defend the ancient theories of Hippocrates."

Our guide tells us that Dr. Bree was the most famous as

The first figure we meet in our journey to the 18th century is famed asthma physician Robert Bree.  He was one of the last asthma experts to defend old asthma theories.  He was an ardent proponent of the bronchitic theory of asthma, although he adjusts it somewhat to support opinions he forms by his own observations.

I'm in the comfortable confines of my time machine, loaf back in my leather chair, and a man with a scruffy beard and tux offers me a cigar.  I decline the offer.  He says, his voice gruff, "I have every brand on the market, including asthma cigarettes.  Just let me know if you're interested.  How about a drink."

He motions at a cabinet containing a variety of spirits. 

"How about a beer," I say, and he clips the top off a brown bottle and pours the contents in a mug.  I take a drink, "Phew!!!" The contents spew from spew from mouth, I drop the mug, and the contents spilling on the rubber matted floor.  "Sorry!" I said.  

"No problem at all," he responds.  "Get that response all the time from you time travelers."

Then why didn't you offer me something more civil? I think, and then dismiss it altogether as I see, through the glass walls of the time capsule, a man I've seen several times on my time journey, and i recognize him right away as Hippocrates, the father of medicine.  

"The treatment of asthma is relative to the cause," my guide says.  "Before Hippocrates, for example, asthma-like diseases were often believed to be caused due to a spirit, and the remedy consisted of chants and hymns to expectorate the evil spirit.  Occasionally a family member  knows of a herbal remedy for you to try, perhaps something mixed in tea, or smoked in a crude pipe."

After clearing throat, he says: "Hippocrates believes asthma is caused by an imbalance of the four humors -- yellow bile, black bile, phlegm and blood -- and diseases are caused by an imbalance of these humors.  This was pretty much the belief of both western and eastern societies, or at least to some extent.  So one remedy is bleeding to expectorate excess blood, and another concoction is believed to warm the patient, and both to balance the humours."

He continues:  "Galen, you met him the other day, Aurelius Celsus, you met him too, and other ancient asthma experts differed slightly in their descriptions and remedies.  Yet for the most part they believed in the humoral theory of asthma.  Yet William Cullen, the asthma expert you met in the 18th century, swayed from these teachings based on science, and he came up with the more modern nervous and spasmotic theories of asthma."

He lights a cigarette.

"Oh, please don't," I say, scoffing at the smoke he creates. "I have asthma."

"Don't worry," he says, smiling, "I have all sorts of asthma powders." He motions at the cabinet of cigarettes and cigars. "It's all good for asthma."

"Not in the modern... er, future world," I say.

"Huh?" he chimes, then seems to ignore my thought and continues:

"Robert Bree, however, was an English physician who believed such modern theories were the subject of quackery.  He set out to prove Cullen wrong and ancient asthma experts closer to the truth in his 1797 book 'A Practical Inquiry into Disordered Respiration, distinguishing the Species of Convulsive Asthma, their Causes, and Indications of Cure.'"  (3)

He hands me an old, worn out book.  It smells like an old worn out book too.  "If you want to meet Dr. Bree you can push this button here," he says. "First of all, he wrote that no science proves the nervous or spasmotic theory of asthma, especially considering those two conditions cannot even be observed in autopsy.  He said you can see phlegm on autopsy, so science supports his theories and those of Galen and Celsus more so than Cullen's.

"Now," he continues, "Bree did not completely reject the spaspotic theory of asthma, he simply considered it as secondary to some other cause.  Ernest Schmiegelow explained this in his book 'Asthma, considered specially in relation to nasal disease."  My guide hands me another book and refers me to page four.

As I'm flipping through the pages I check the date as 1890, and then proceed to page four.  He directs me to the following:

"Bree does not actually deny the possibility of bronchial spasms taking some part in the cause of asthma, but it is only secondary; the primary cause is an exudation in the bronchial tubes, by which the lungs (specially the muscles of respiration) are stimulated to contraction, in order to expel the mucus which they contain." (4)

My guide explains:  "In other words, Bree believed that mucus was the cause of most diseases, including asthma.  He believed the contraction of the lungs was a defense mechanism to expel mucus from the lungs. Bree's ideas about asthma are important to our 19th century history because he is considered by many the preeminent asthma expert of the first half of that century."

He grabs the book off my lap, and hands me another.  It was a book I own, and that sits on my nightstand.  Only this copy, I see as a peruse it, doesn't have all my markings in it. The book is "Asthma: A Biography," by Mark Jackson.

He says,  "George Lipscomb is a fellow asthma expert from England who set out to prove Bree wrong.  As Mark Jackson describes in his 2006 book, 'Asthma: The Biography,' the book that now sits on your lap, Lipscomb's goal was not to discredit Bree, his goal was to 'elucidate the history of a very prevalent and distressing disease, which has been hitherto but ill explained, and very unsuccessfully treated.''

He hands me another old book.  "Lipscomb published his own theories in this 1800 in this book: "Observations on the history and Cause of Asthma."  Lipscomb argued that Bree could no more prove Cullen's theories were wrong than Cullen could prove them right because upon death the lungs automatically relax." (5)

"Interesting," I say, "Very interesting.

"So the debate was on.  While experts are hard pressed to find evidence to prove either theory, Schmiegelow explains that Bree's theory is disproved as soon as the stethoscope gains favor, as it's easily proven an attack of bronchitis does not precede asthma, and that rhales, a lung sound Rene Laennec used to describe secretions in the lungs, are heard later during the attack.

"Likewise," he concludes, "while Bree is well respected in his day, his ideas about asthma, and even most of his remedies, slowly give way to to the spasmotic theory of asthma and the nervous theory of asthma.  These and other theories are debated throughout the century."

Continue the journey by clicking here.

References:

1. Pepper, William,  Louis Star, "A System of Practical Medicine," Volume 3, page 184
2. Berkart, J.B., "On Asthma: It's pathology and treatment," 1878, London,  Chapter II, "History of Asthma," page 12
3. Bree, Robert, "A Practical Inquiry into Disordered Respiration, distinguishing the Species of Convulsive Asthma, their Causes, and Indications of Cure, London, 1810.  I could not find the 1790 edition online, yet this one serves our purpose.
4. Schmiegelow, Ernest, "Asthma, considered specially in relation to nasal disease," 1890, London, page 4 
5. Jackson, Mark, "Asthma: The biography," 2009, London, pages 86-88 (If you're interested in a good asthma history book, this is it.)

1800-1900: Debunking ancient asthma theories

Today I continue to describe my quest (that we started here) through the 19th century learning as much as I can about asthma.  My guide is a gruffy gentleman with a scruffy beard, offers me a cup of Joe, which is something more up my alley than the cigarette and shot of whisky he offered me earlier.

I lean back in my cozy little chair and put my feet on the ledge by the glass, something my guide has already done.  The time machine already took me back to 400 B.C and where I watched  Hippocrates and his fellow physicians study respiratory disorders and work on defining asthma as a medical term.

We're presently in the year 1816 on a hot and humid day in France.  My guide describes the man I'm watching as Rene Laennec.  The physician is leaning forwardwith his ear pressed on one end of rolled up bundle of papers, with the other end of the tube on the chest of a large, dusky, perspiring lady who's hunched up on the doctor's bed panting for air.

"The object he's using is clearly the first stethoscope," my guide says, "yet on this day he humbly refers to it  as le cylindre.  It will be a few years before Laennec is pressured by his peers into calling his object the stethoscope.  Regardless, this would turn out to be a revolutionary device responsible for the evolution of a term called asthma throughout the rest of the 19th century.  Laennec perhaps had no clue his invention would set off a hunt to redefine asthma, or at least provide the tool for such a task."

My guide continues, as Laennec continues to listen to the ladies lungs using his object.  He sets the end opposite his ear at various points on the ladies chest, both front and back.  The lady sits patiently while she continues to breath heavily.  "Over the ensuing years, which will go by fast in the comfy confines of our time machine, we will see a growing number of physicians using this tool to help them better diagnose and treat their patients.  And it's mainly this tool that sparks a hunt by asthma physicians to redefine asthma so it represents the disease as you know it."  He points at me.  "Yet how this evolution occurs is the purpose of our journey through time."   

Laennec's stethoscope

He says, "Through our travels thus far we've learned the Ancient Greeks used the term asthma to describe any condition that causes dyspnea, or shortness of breath.  So dyspnea could be caused by cardiac asthma (what you call heart failure), or humoral asthma (what you call chronic bronchitis), or kidney asthma (what you call kidney failure).

"William Pepper and Louis Star, in their 1885 book "'A System of Practical Medicine' explain that prior to the 19th century all dyspnea and all that wheezes were designated as asthma."

He continues, "John Floyer was the first to separate asthma from dyspnea, yet it was Rene Laennec who was the first to think of asthma as a term abused by the medical community.  He came up with the idea that many cases of asthma are actually heart disease, chronic bronchitis or kidney disease, not asthma.  So he spent a lot of time studying the signs and symptoms of his patients and comparing them with what he found on autopsy.



He reaches for a cigar, places it between his lips, and pretends to puff on it.  He hands you a book with that title, and opens it for you to page 184, where the following is highlighted using a 20th century marker:

 "These guys wrote about the term as covering such an 'extensive range of territory, it was found necessary to subdivide the disease into a number of varieties, each author classifying them according to his conception of the cause, seat, and nature of the trouble. Some of these -- e.g.a. dispepticum (upset stomach), still find their place in medical literature, but the vast majority of them, having ceased to be of any practical significance, have been discarded, and are now only interesting as examples of the crude and fanciful notions which prevailed in an age during which science rather retrograde than advanced." (1)

He took back that book and handed me one I often refer to at Google Books back home: an 1878  book by J.B. Berkart titled "On Asthma: It's pathology and treatment."   I set the book on my lap, and he says, "Open it to page twelve."

Here, on page 12, the following is highlighted:

"ALL early historical traces of the affection at present called asthma are lost. Although the disease is said to be mentioned in the Bible, and described by Hippocrates, Areteaus, Galen, and Celsus, there is not the least evidence that those remarks apply to the asthma of to-day. For in the former systems of medicine, all cases presenting the same conspicuous symptoms were, regardless of their anatomical differences, considered as of a kindred nature, and grouped into classes according to imaginary types. (2)

Laennec is now standing before the lady after his long assessment of the ladies chest  It appears that he even has a short smirk of joy on his face, knowing, perhaps, he is on to something with his invention here.  "I know these highlighted phrases are almost trivial, although I find it interesting because these physicians, in this era, were privy to the idea that they were taking part in the rapid evolution of the disease they were studying -- asthma.

My guide continues, "In essence, Laennec's discovery sparks a leap through time.  Where 7,000 years of asthma suffering results in little progress in the way of asthma wisdom and treatment, the next 81 years -- part of which we are now observing -- provides for asthmatics more than all those 7,000 years combined. I think that Pepper and Star and Berkart were well aware that this was happening.

"And we learn that between 1816 and 1900 many different theories about what causes asthma are created, and every one of these theories has followers.  Each expert writes his own definition of asthma based on his beliefs about the disease, and his own remedies based on these beliefs."

He explains that this is all done in the process of fine tuning the definition of asthma.  Yet in the end, the two theories that win the day are:

1. Bronchospasm theory of asthma (a.k.a. spasmotic or convulsive)
2. Nervous theory of asthma (a.k.a. it's all in your head)

By the end of the 19th century the ground is set for an even bigger leap through time as far as asthmatics are concerned.  By 1899 adrenaline is isolated, and this sets off a wave of wisdom that greatly improves the lives of asthmatics. Yet for the time being (no pun intended), we find ourselves drifting from cozy doctor's offices in large Victorian homes to laboratories of some of the worlds greatest asthma experts. 

Continue the journey by clicking here.  

Click here for more asthma history.

References:

1. Pepper, William,  Louis Star, "A System of Practical Medicine," Volume 3, page 184
2. Berkart, J.B., "On Asthma: It's pathology and treatment," 1878, London,  Chapter II, "History of Asthma," page 12

Classic toddler asthma signs easily overlooked

Yes it's true that even your humble RT and lifelong asthmatic can over look the classic signs of asthma.  My 3 YO HM woke at 2:30 in the morning, was agitated, coughing, and was annoying her father.  He even yelled at her, because he thought she was simply caught in that flux between sleep and reality.

He finally set her back in bed and decided she'd eventually fall asleep.  He hopped into his own bed, and his wife said, "Did you give her her pulmicort before bed last night.  Sometimes she has asthma when she doesn't get it."

Bingo!  He could have slapped himself up alongside the head.  He carried the little girl to the living room, set her in the recliner, prepared a breathing treatment with pulmicort and ventolin, and gave it to her by blowby.  Within minutes her breathing was easy and she was sound asleep.  

He set her back in bed and not a peep was heard the rest of the night.  This was a perfect real life example of how even the most expert of asthma experts can overlook the classic signs of asthma.

 It's a also a quintessential example of how important it is that everyone responsible for a child know about the signs of asthma.  When one person misses the signs, perhaps the other will pick up on them.  

I suppose it's also a classic example of the importance of good teamwork.  Regardless, she is doing great today, that little asthma girl.  No longer will we be able to skip a dose of pulmicort.  

2012 Inhaled Corticosteroids on the market

Inhaled corticosteroids continue to be a top line option for treating asthma.  As of January 30, 2012, the following are options available to asthmatics:

• Aerobid
• Azmacort
• Qvar
• Flovent HFA
• Azmanex Twisthaler

According to the FDA.gov, any one of the above will work to control asthma.  An interesting thing to note is that the FDA mentioned that every new inhaled corticosteroid to hit the market since beclomethasone in 1960 was just a little stronger and a little safer than the one before it.  If this is true, Azmanex would be the best inhaled corticosteroid.  It's also available in the combination inhaler Dulera (a medicine similar to Advair and Symbicort).

Another neat thing to mention is that the HFA propellant appears to be finer than the CFC propellant, which means the inhaled corticosteroids may get deeper into the lungs to provide better distribution of the medicine.  This has been proven by some studies.  Some hardluck asthmatics have been experimenting taking a few puffs a day of Qvar to go along with their Advair, or Symbicort, or Dulera.

I believe at the present time there will soon be another inhaled steroid on the market, and I think there are already attempts being made to have it released in a combination inhaler with fluticasone (Flovent).  Fluticasone is presently combined with Salmeterol (Sevevent) in Advair.