History of spirometry (the pulmonary function test)

John Hutchinson (1811-1861)

If you're an asthmatic chances are your doctor has had you perform a pulmonary function test (PFT).  The Mayo Clinic states this is a test that measures how much air you can blow in and out, and it's a good test to help your doctor diagnose asthma or to monitor the course of your asthma over time.

During this test you blow into a spirometer which measures your lung volumes, and it's for this reason PFT testing is more historically referred to as spirometry.  Over the past 30 years I've performed hundreds of these tests, and while my PFTs now are relatively normal, once when I was about 14 I had a PFT test show I had only a 35 percent lung function (obviously it was during an asthma attack).

The first known recorded spirometry test was performed by Greco-Roman physician Claudius Galen way back in the period of 129-200 A.D.  He had a boy blow into and out of a bladder, and he found that the volumes exhaled do not change over time.  Yet Galen wasn't able to measure the volumes, he simply used his keen eye and observation, according to Ann Kiraly in her 2005 award winning article, "History of Spirometry." (1)

While others may have performed similar experiments nothing significant was recorded until Giovannin Alfonso Borelli (1608-1679)  had a volunteer plug his nose to assure an accurate measurement of lung volumes, and to prevent air from escaping or entering from the nose.  He is believed to be the first person to have have a patient block the nose, a technique that is still done to this day during spirometry testing. (2)

In 1679 Borelli became the first to measure the amount of air entering the lungs.  He did this by sucking liquid up a tube.  (3)  In 1790 James Watt invented the gasometer, a container that stores gas, that permitted "Thomas Beddoes (1760-1808) to to lay the foundation of pneumotherapy."  (4, page 29)  Beddoes used his research to found the "Pneumatic Institute at Clifton for the treatment of disease by inhalation.  (5, page 336)

In 1793 John Abernathy developed a method of collecting expired gas over mercury and attempted to determine how much those gases had been used up by the body.  He thought this was important because exhaled oxygen should be less than what is inhaled.  He also determined that exhaled oxygen would be higher in patients with certain lung diseases. (2)

He also measured a vital capacity (VC) of  3110.   (2)  Vital capacity is the total amount of air one can exhale from the lungs after a full inspiration. A VC of 3110 may have been normal for that person, considering a normal VC is now determined to be 4-5 liters.

Figure 2 -- Davey's Gasometer* *(4)

In 1800 Sir Humphrey Davey (1778-1829), assistant to Beddoes, used the gasometer of Watt to measure various lung volumes.  He measured his own vital capacity at 3110 ml. (2 and 5)

He measured his tidal volume at 210 ml.  Tidal volume (VT) is another word for normal breath. A VT seems kind of low, although it may have been normal based on Davey's height and age. (4)

He also calculated his residual volume to be about 600 ml.  (4)  Residual volume (RV) is the amount of air that stays in your lungs after a normal exhalation. It's physiologically necessary to prevent your alveoli from collapsing.  Alveoli are microscopic baloon-like structures at the end of air passages, and by keeping a little air in them at all times it's easier for them to be re-opened when you inhale.  It's kind of like the first time you try to blow up a balloon it's harder than the second time.  So, in this way, residual volume is good and normal.

Figure 3 -- Lung Capacity Chart -- 1903 (1, page 27)

To put these volumes into perspective, VC = RV + TV.  While the technique used is now different, these same volumes are measured by today's spirometers.  (See Figure 3)  Davey also devised a mechanism to determine how much oxygen was utilized by the body and how much carbon dioxide his body created.  (2)

In the following years many others performed similar experiments.  Herman Boerhaave (1668-1738) "measured the difference in the level of water in his bath tub during the two phases of respiration,"   according to Paul Lois Tissier in his 1903 book "Pneumotherapy: Including Aerotherapy and Inhalation Methods and Therapy. (4)

Davy and several others collected air in a bell-jar filled with water.  So there were various techniques performed by a variety of physicians and scientists from the 1660s to 1840s where attempts were made to measure lung volumes.  Yet it wasn't until 1846 that an effective spirometer was invented, and the inventor given credit is John Hutchinson. (4, page 29)

By this time it was well known among the medical community what the normal lung volumes were and the physiological advantages of being able to measure them.  It was known that the respiratory capacity varied with age and height, and that the respiratory capacity continues to increase until about the age of 20, and that the vital capacity of men was "considerably more" than women. (4, page 28)

Hutchinson's Spirometer

Tissier explained that Hutchinson "taught the importance of physiologic research and devised the instrument which bares his name."  Basically Hutchinson's spirometer is a combination of techniques used by other inventors who existed before him.  For example, his consisted of a bell jar immersed in water.  (4)

Tissier explained Hutchinson's spirometer this way:  "The jar hung in cords which pass over pulleys attached to two vertical supports, is counterbalanced by weights. The air, first expired by a mask applied to the patient's mouth, is conducted through an external rubber tube and then through a metallic tube in the interior of the reservoir to the upper portion of the bell jars.  As soon as expiration takes place, the air enters the jar and the later rises.  The distance transversed by the jar is read on a graduated scale, and the volume of expired air is then calculated." (4, page 29)

Schnepf (4, page 30)

Hutchinson determined that the volume of exhaled air (VC) has a linear relationship with height.  As we now know, the taller a person the longer the lungs, and the more air they can hold.  In other words, he was right.  

Hutchinson also invented a portable spirometer "where respiratory capacity is measured by the movement of a pointer."  By the turn of the 19th century Hutchinson's model had been modified "but a little."  (4, page 29)

The most significant adjustment to this device was made by Dr. Wintrich in 1856 who adjusted the bell jar so that it was movable and supported by a single rod.  Most experts believed Wintrich's improvements made the Hutchinson's spirometer much more accurate and much more easy to use. (4, page 29)

Kiraly explained that Wintrich was also the first to determine that the best way to measure VC can be estimated by a measurement of a person's height, age and weight.  This same measurement is used to this day. (2)

Various other spirometers were invented in the following years.  In 1854 Boudin created a spirometer that was more convenient but less accurate.  In 1856 Schnepf connected the bell jar to chain, "the links of which are of equal lengths so as to compensate for variations in the weight of the jar, according as it is immersed to a greater or lesser depth in the water of the reservoir." (4, page 30)

In 1856 Bonnet invented Bonnet's Apparatus, which "used an ordinary gasometer for a spirometer."  Yet Tissier recommends not using this device because it uses pressure to measure changes in lung volumes, and it may well be confused with the various pressure devices he describes later in his book (a post on these will be published on 8/5/14).

Another alternative was the Barnes Dry Spirometer, which was "Within a closed cylinder of metal is placed a rubber bag, which, when inflated, pushes up an index rod graduated to show cubic inches."  (4, page 32) This device was introduced in 1865. (6, page 894)

And there were many other variations of the spirometer over the next decades.  (4, page 32)

Boudin's Respirator (4, page 30)

So the spirometer has been modified many times through the years since Hutchinson's invention, yet the only significant changes are that graphics are now used and the bell jar is smaller.  Oh, and we should also note the system has now been computerized.

Either way, spirometry, often referred to as pulmonary function testing (PFT),  remains a significant test used to help physicians diagnose and monitor the course of disease.

---

Barnes Dry Spirometer (4, page 32)

References:

1. Creative-biotech.com, "History of Spirometry and Lung Function Test, http://creative-biotech.com/special-offer/history-of-spirometry-and-lung-function-test/
2. Kirally, Ann, "History of Spirometry,", Journal of Pre-health Affiliated Students, JPHAS, Winter 2005, Volume 4, Issue 1,  
3. Brockbank, E.M., ed., "The Medical Chronicle: A Monthly Record of the Progress in Medical Science," October 1905 to March 1906, Vol. XLIII, Boston, page 301,
4. Tissier, Paul Lois, "Pneumotherapy: Including Aerotherapy and Inhalation Methods and Therapy," 1903, Philadelphia,  page 29)  Herman Boerhaave (1668-1738) 
5. Garrison, Fielding Hudson, "An introduction to the history of medicine," 3rd ed., 1922, Philadelphia, W.B. Saunders
6. "Commissioner of Patents," "Executive Documents printed by order of the House of Representatives during the first session of the thrity ninth congress," 1865-6, 16 volumes, Washington, Government Printing Office
7. *Pictures compliments of JPHAS

Further readings:

1. You can read more about some of the 19th century spirometers and even see some pictures by clicking here.  
2. To read an awesome and much more precise account of the history of the spirometer check out Ann Kiraly's article ," which was a 2nd place entry in the Spring 2004 Health Science Writing Competition.  Her article was published in the Journal for Pre Health Affiliated Students and can be reached by clicking here.  

1800-1900: okay, so what really causes asthma

Remember Budd?  He's our asthma expert from 1840 who flat out rejected the bronchospasm theory of asthma.  In 1855 Guillaume Benjamin Amand Duchenne proved Budd right, or so he thought.  As Berkart wrote, Duchenn proved "faradisation of the phrenic nerve caused tetanus of the diaphragm.  (You can view Duchen's book here**)

So who cares what causes the symptoms, Berkart wrote of Constatt, who believed it doesn't matter the cause of dyspnea because antispasmotics (like belladona found in asthma cigarettes) work equally well for both asthma and emphysema.

Pretty much Constatt was correct, yet with greater wisdom comes greater treatments as we would learn in 1900.

Another neat theory that came along in 1855 was by a Dr. Ludwig Traube who denied nervous asthma but believed asthma was rare and the dyspnea that resulted was caused by "fluxionary hyperaemia of the bronchial mucous membrane."  What he is referring to here is "swelling of the bronchial mucus membrane," wrote Berkart.  This is what we now refer to as inflammation.

Traube also believed asthma was caused by sputum in the air passages of the lungs, according to Jackson.

Ah, if we could only jump into our time machine we could tell Traube he was on the right track.  It would take another 130 years for asthma experts to realize Traube was on the right track, that asthma is a disease of chronic inflammation.

Likewise, Traube wrote that this inflammation cannot be diagnosed during a person's lifetime, and can only be diagnosed by the symptoms it presents with, such as dyspnea and wheezing.

Then in 1859 Bervenisti, as Berkart continued, brought attention once again to the differentiation of the different causes of lung diseases that he believed were probably unrelated to asthma.  He (Bervenisti) believed that a doctor could not possibly diagnose bronchospasm by listening to lung sounds alone.  That sonorouis and sibilant rhonchi are also present with a pulmonary embolism, which also causes dyspnea.

Once again, if we could jump into our time machine we could tell him he was right, that lung sounds can help with a differential diagnosis.  For example, heart failure would result in coarse crackles throughout the lungs or half way up, pneumonia often results in crackles in one lobe of the lungs, a wheeze indicative of air traveling through narrowed air passages (asthma), and rhonchi indicative of air traveling through sputum (bronchitis).

In a way I'd like Mr. Bervenisti to come talk to the doctors that exist today who still believe all dyspnea is bronchospasm.  I'd like Mr. Bervenisti to set them straight.

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)," 18

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