1810: Bree's asthma remedies

Dr. Robert Bree was recognized as a predominant expert on asthma during the first half of the 19th century, as I wrote here.  In 1910 he wrote a book titled, "A Practical Inquiry into Disordered Respiration Distinguishing the Species of Convulsive Asthma, their Causes and Indication for a Cure."  The following are the remedies he recommends for asthma:

1.  Cathartics:  These are medicines or herbs that cause evacuation of the bowels, or purging.  Purging is the use of vomiting or laxitives to clear the stomach, according to dictionary.com.  For example, one patinet noted taking "10 grains of powder of jalap, and three grains of colomel when the fit commenced, which completely removed the fit, on many occasions by evacuating a load of bile."  Yet Bree wasn't a big fan of cathertics, and suggested that if this relieved the asthma the cause was something other than asthma.  However, he admits that cathertics to work for some asthmatics. 

2.  Emetics:  These are medicines that induce vomiting, according to Dictionary.com.  Tartarized Antimony and Antimonial Wine or small doses of Ipecacohan can incuce vomiting.  Amid other things, they promote exhalation from the lungs and are therefore "powerful expectorants."

3.  Diaphoretics:  These are medicines that promote sweating, according to dictionary.com  He recommended "gentle diaphoresis, but not sweating." 

4.  Bleeding:  This is where you cut a vein and allow blood to flow in an attempt to balance the humors.  He believes this has "doubtful effects" on asthmatics.  However, he does recommend it for most species of asthma. 

5.  Diuretics: These are medicines that make you pee.  "Natron taken every night, in doses of eight grains, has been found to be very beneficial" for certain types of asthma. 

6.  Issues:  These are medicines to treat mental or emotional problems, according to dictionary.com.  "In very old asthmatics, issues are sometimes necessary.  In younger subjects, when the disease is not yet inveterate, they may occasionally be useful, by diverting acqueous humour from the lungs, and giving a better opportunity for the operation of tonic remedies...  When the disease is complicated by dropsy (an old term for edema, according to dictionary.com), I have seen great advantage to the breathing, from from their application in the thighs." 

7.  Antispasmotics:  These are medicines that relax smooth muscles, such as the muscles that wrap around the air passages in the lungs or that line the respiratory tract.  One common medicine is opium and it is enhance by the use of ether.  Calcined zinc has proven beneficial for epilepsy, although is not useful for asthma.  "Velerian, cardamine, camphor, musk, castor, belladonna, tobacco infusion, extract of  henbane, fetid gums, cuprum ammoniacle in various doses, more or less joined with the other antispasmotics, or tonic medicines, and combined with opium in large and small portions" helps sometimes but most often prolongs the paraoxym. 

8.  Expectorants:  These are medicines that induce sputum production.  Ammoniac is a very valueable expectorant, although it should be given with opium to prevent purging (unless you want purging).  Squills are sometimes useful.  Squills also work when given with vinegar, similar to what John Floyer prescribed.  This is often called vinegar of squills.  A side effect is nausea and purging.  Tincture of squills combined with extract of henbane and the nitric acid is a good combination of expectorant and sedative.  Oxymell is efficatious if combined with vinegar or squill.  Honey and sugar are good for cough, but not so much for asthma.  Decoction of seneca can be useful in older persons, but is too irritating for younger people.  If asthma takes on the character of peripneumonia, decoction of seneca should be given with amonia during the febrile state, and when the fever goes away squill and camphorated tincture of opium will promote expectoration, perspiration, and urine.  All expectorants may cause nausea and vomiting, and this may be good in that it may remove the irritaing matter.  However, they also help relieve phlegm from the chest.

9.  Inhaling vapours:  "Hippocrates introduced the inhalation of vapours from various herbs and gums.  He used herbs and nitre boiled with vinegar and oil, and directed the vapour of such boiling compositions to be drawn into the lungs through a proper pipe."  Fumes can also be used to dry secretions that are known to cause asthma.  Frankincense, myrth, and many other gums, and these are occasionally mixed with arsenic. 
Modern physicians recommended inhaling vapour of aether "raised in the steam of warm water."  However, aether can make asthma worse.  Vapour of hemlock leaves can be useful for some forms of asthma, and especially for it's narcotic qualities. 

10.  Smoking tobacco:  Bree actually recommends asthmatics stop smoking "with great advantage to their health." 

11.  Oxygen:  May benefit asthma when the color of the skin turns blue.  May help cease labored respirations.  It works expecially well for convulsive asthma. 

12.  Hydrogen:  This has been proven to be beneficial to asthmatics, particularly spasmotic asthma. 

13.  Stomachics:  "These remedies are absolutely necessary in asthma to correct dyspepsia (upset stomach), in whatever species of the disease it may appear.  Bitter tinctures are not to be used in the paroxysm, but bitter infusions and testaceous powders are generally beneficial.  Acetous acid is also grateful to the stomach when any bilious acrimony is present.  In this case "

14.  Diet:  Any food that is an exciting cause of asthma should be avoided.  Barley water and all weak liquors that are likely to ferment or relax the stomach should be avoided.  Infusion of coffee is good for any type of asthma except the second. "Pure cool water has frequently removed the bad effect of an imprudent meal.  If the asthmatic perceive his stomach to be disordered or uneasy, he may next expect more certain symptoms of a paroxysm.  In these circumstances I have experienced, very frequently, the advantage of repeated draughts of water, so that two or three pints have been taken in the whole, from the commencement of the uneasiness; and this has given perfect relief when coffee had failed."  It is wise not to eat more than the stomach can handle."  (page 204)

Note:  According to Bree, the above remedies vary in accordance to the species of asthma diagnosed by the doctor.  However, in order to simplify Bree's work I have left out which species of asthma the above remedies are for.  In either case, all of the above remedies were recommended for one or another species of asthma.  I did find Bree's writings to be quite complicated to understand, and I apologize if my interpretations of Bree's work isn't exactly as he understood.

References:

• Bree, Robert, "A Practical Inquiry into Disordered Respiration Distinguishing the Species of Convulsive Asthma, their Causes and Indication for a Cure," 1810, London, 4th ed., items 1-13 are obtained from pages 237-278, item 14 from page 292-294

A brief history of pneumonia

Pneumonia is inflammation of lung tissuePneumonia may possibly be the leading cause of death all time.  Surely other maladies popped their ugly heads from time to time, and surely tuberculosis gave it a run for it's money, yet one consistent and deadly malady throughout human existence is that of pneumonia.

Statistics show that from 1900 to 1937 pneumonia was annually either the number one or number two cause of death, with tuberculosis competing with it for the top spot.  (1)  Statistics prior to 1900 are sparse, yet one might be right to assume pneumonia was consistently a leading cause of death since the beginning of human existence.

Pneumonia is also among the oldest diseases to have a diagnosis in medicine.  The Hippocratic writers described the malady as far back as 400 B.C. in the Hippocratic Corpus.  Yet we know it was diagnosed much earlier than this, considering the Hippocratic writers credited pneumonia as being "described by the ancients."

Signs and symptoms of the disease would have been well known to Greek physicians, and for those who performed autopsies, evidence of the illness would have likewise been visible.  Hippocrates described the condition as such:

"Peripneumonia, and pleuricic affections, are to be thus observed:  If the fever be acute, and if there be pains on either side, or in both, and if expiration be if cough be present, and the sputa expectorated be of a blond or livid color, or likewise thin, frothy, and florid, or having any other character different from the common."

Dictionary.com describes pneumon as latin for lung or lung and pneuma as latin for lung.  So pneumonia refers to a condition of the lung.

Pleurisy was defined by the Ancient Greeks as inflammation of the pleural cavity, and they recognized symptoms of pleurisy and pneumonia as a sharp pain in the side.  Hippocratic writers simply grouped these two conditions together under the phrase peripneumonia. (8, page 192).  The condition may also have been confused with other maladies such as asthma or heart failure, which were generally grouped under the umbrella term asthma.  (2, page 3) 

During the ancient ancient world, there were essentially only three diseases that affected breathing, and they were tuberculosis, asthma, and pneumonia.  Pretty much everything else that caused breathing trouble was grouped under the umbrella term asthma, which was pretty much a generic term for shortness of breath.  Pneumonia was not asthma because even the ancients could see that parts of the lung was full of inflammation, secretions, and pus. 

Treatment might include any of the following, depending on the stage of the illness, age of the patient, color of the sputum, and season of the year (6)

16th century doctor bleeding a patient*

• Bleeding
• If fever, the bowels were opened with clysters
• If pain, hot water in a bottle or bladder, a sponge of hot water, or cataplasm of linseed was applied to the hypochondrium
• Linctus containing galbanum and pine fruit in Attic Honey or...
• Sothernwood in oxymel
• Oppaponax (a bitter resin with a garlic taste) mixed in oxymel
• Drink of ptisan made from huskey barley and mixed with oxymel

The hippocratic writers were aware of when the disease was getting better or worse (6)

"When pneumonia is at its height, the case is beyond remedy if he is not purged, and it is bad if he has dyspnoea, and urine that is thin and acrid, and if sweats come out about the neck and head, for such sweats are bad, as proceeding from the suffocation, rales, and the violence of the disease which is obtaining the upper hand, unless there be a copious evacuation of thick urine, and the sputa be concocted; when either of these comes on spontaneously, that will carry off the disease."

Plutarch (46-120 A.D.)

Plutarch (46-120 A.D.) recognized that while pleurisy often accompanied pneumonia and may have been responsible for the pleuritic chest pain and fever, it sometimes occurred on its own.  He decided that the term peripneumonia was superfluous, and therefore referred to inflammation of the lungs as pneumnonia, and inflammation of the pleural sac as pleurisy. (6, 8)

Hippocrates noted that death from pneumonia usually occurs on the seventh day.  Areteaus of Cappadocia, about 140 A.D., concurred with Hippocrates that death usually ensues on the sevenths day.  He wrote about the usefulness of the lungs, and explained that certain maladies can cause havoc: (6)

"But if the lungs be affected,  from a slight cause there is difficulty breathing, the patient lives miserably, and death is the issue, unless someone effects a cure.  But in a general affection, such as inflammation, there is a sense of suffocation, loss of speech and breathing, and a speedy death.  This is what we call peripneumonia, being an inflammation of the lungs, with acute fever, when they are attended with heaviness of the chest, freedom from pain, provided the lungs alone are inflamed."

The cure Areteaus wrote about for pneumonia was similar to that of Hippocrates, although he added the following to the list of options:  (6)

• Wine
• Hysopp
• Rubafacients containing mustard applied to the chest
• Diluent drinks

Claudius Galen of Pergamum was an ancient Greek physician (120-210 A.D.) who became one of the most prolific writers of medicine after Hippocrates.  He wrote one of the most famous medical journals that was worshiped by physicians for 1500 years after his death.  He is believed to be the first to differentiate between pneumonia and pleurisy, although he continued to refer to them as peripneumonia. (6, page 2)  His remedies for the malady were similar to those of Hippocrates.

Maimonides (1138-1204 AD), whose medical writings were well respected for many years, described:  "The basic symptoms which occur in pneumonia and which are never lacking are as  follows:  acute fever, sticking (pleuritic) pain in the side, short rapid breaths, serrated pulse and cough."  This was the first recorded description of the same signs of pneumonia as we define it in modern times.

Even Scottish physician and asthmatic William Cullen (1710-1790) explained pneumonia as either inflammation of the "viscera of the thorax or the membrane lining that cavity."  In 1792 Dr. Jean P. Frank mentioned that pneumonia "must be studied under the common name pleuro-pneumonia."(2, page 3)

Octavius Sturges, in his book, "The Natural History and Relations of Pneumonis," explains that while one cannot deny historic accounts and descriptions of epidemics were accurate, the descriptions of the way people died were often eerily similar to what doctors of today would diagnose as pneumonia.    

So while people suffering from the Black Plague, for example, may actually have been infested with the disease, many may have had their immune systems so wiped out that it was easy for pneumonia to set in.  This may explain monk descriptions as cough, bloody spitting, diarrhea and vomiting and fever, catarrh, difficulty breathing, pain in the side, weakness, delirium and quite often death.

Sturges also describes how the garrison of Philisbourg in 1688 that was attributed to exposure to a "cold north wind... and camp life."  One common treatment was bleeding.  Autopsies on him and others inflicted with pneumonia (or what was diagnosed as pneumonia) were described as "actively inflamed and hepatised, and in many parts purulent, the chest and pericardium filled with bloody serum and polypi in the right auricle of the heart." (2)

Hermann Boerhaave  (1668-1738) published Aphorisms in 1709 and described that lobar pneumonia should be recognized as a separate disease from other infections of the lungs.  (6, page 3)

Giovanni Battista Morgagni (1682-1771) recognized, that pneumonia caused a solidification in a lobe of the lungs and referred to it as lobar pneumonia. (8)

John Huxham (1692-1768) studied the writings of Hippocrates, Celsus and Aureatus, and, based on his own observations of diseases, came up with remedies for various medical conditions. One thing of significance regarding Huxham is he was in ardent opposition to what he referred to as quack medical therapy.  For the treatment of pneumonia he developed a procedure called the "Huxham tincture."  It was a medicinal drink that was recommended by physicians for many years.

Matthew Ballie (1761-1823) spent quality time performing post mortem studies, and he described many diseases of the lungs.  He described the inflamed parts of the lungs (pneumonia) as being covered by a solid mass similar to a liver, and he referred to it as "hepatisation."  (8)  ( in his book "Morbid Anatomy of Some of the Most Important Parts of the Human Body," in 1793)

Dr. Thomas Addison (1783-1860) was the first to write about pneumonia not being a disease that affected just the "interstices" of the lungs but the "air vessicles" themselves.

Carl von  Rokitansky (1804-1878)  was the first to describe lobar pneumonia.  Rokatansky described that "The red inflammatory product becomes gray and compact and indurated.  The air cells contract over the granulations, coalesce with them round their circumference, and become obliterated, their tissue being changed into a fibro-cellular structure, in which, from the similarity of their organization, the granulations are most probably also merged." (10)

Throughout 18th century phlebotomy or bleeding continued to be a common treatment as it was during the time of Hippocrates.  Many examples of pneumonia or pneumonia-like symptoms were described in medical writings and autopsies.  It is likewise believed that an aging George Washington had acquired pneumonia. As a treatment he was bled, and many historians believe it was this bleeding that caused his death more so than the pneumonia.

Pneumonia symptoms were also described during influenza outbreaks, which suggest that the flu weakened the immune response to the point where pneumonia set it.  Such an outbreak occurred in 1762, 1775, 1782 and again in 1837.  Outbreaks became less common by the end of the 19th century, yet I would imagine it continued to be a leading cause of death, as it was documented as such when statistics were recorded in 1900.

 In all the above cases where influenza is believed to have lead to pneumonia, characteristic symptoms were described.  And following the cases that resulted in death, inflammation of the lungs was described in autopsy reports.

Various physicians described a pneumococcus associated with patients with lobar pneumonia.  In 1880 Sternberg found it in the saliva, and in 1881 Louis Pasteur discovered the same.  In 1882 Ernst victor von Leyden and Gunther drew fluid from hepatized lungs of living pneumonia patients and discovered pneumococci in this fluid.  Yet in all of these cases the significance of the discovery went unnoticed.  (8)

In 1875 Edwin Klebs became the first to associate pneumonia with bacteria. A few years later Karl Friedlander and Hans Christian Gram started working together in the morgue of a hospital in Berlin and added to Klebs work by identifying the specific types of bacteria associated with pneumonia.

In 1882 Friedlander isolated streptococcus Pneunomiae in the sputum of a patient inflicted with pneumonia, and in 1884 Gram isolated Klebsiella Pneumoniae in the sputum of a patient  inflicted with pneumonia.

The procedure that Gram described when writing of his discovery was later called the gram stain.  It's a technique where a small sample of the sputum is stained, and this causes the cell walls of the bacteria to turn a certain color so the bacteria can be clearly identified. 

This technique is still used in labs to this day.  Yet while Gram simply used the technique to identify bacteria in sputum samples, it's used today to distinguish between different types of bacteria.

In 1888 Nikolia Fedorovich Gamaleia was working in Pasteur's lab when he inoculated sheep and dog with pneumococcus and this caused lobar pneumonia in these animals.  This experiment proved that pneumococcus was the cause of lobar pneumonia.  Gamaleia is also credited in 1888 as discovering bacteriolysins that destroy bacteria.  (11)  He also worked with pasteur to improve the process of inoculation.

By 1891 interstitial changes may occur in acute lobar pneumonia and this may result in fibroid pneumonia (fibrosis of the lungs), and this will be chronic.  (10, page 1309)

In 1896 French student Ernest Duchesne discovered penicillin, yet the significance of his discovery went unknown, and the discovery was left hanging.

William Henry Osler (1849-1919) was one of the most famous physicians during the late 19th century and early 20th century.  His textbook, "The Principles and Practice of Medicine," was quickly accepted as a standard medical text by medical schools, and updated editions of this text were used until 2001.  For this and his other medical contributions he is often referred to as the father of modern medicine.

In the earlier editions he mentioned using oxygen for emphysema and asthma, and by the 1898, or the third edition, he finally recommended oxygen for pneumonia.  However, while he mentions oxygen as an option, he rarely prescribed it for his patients.

He wrote, "It is doubtful whether the inhalation of oxygen in pneumonia is really beneficial.  Personally, when called in consultation in a case, if I see the oxygen cylinder at the bedside I feel the prognosis to be extremely grave.  It does sometimes seem to give transitory relief and to diminish the cyanosis.  It is harmless, its exhibition is very simple, and the process need not be all that disturbing to the patient.  The gas may be allowed to flow gently from the nozzle directly under the nostrils of the patient, or it may be administered every alternate 15 minutes through a mask." (12)

By 1918 pneumonia became the leading cause of death, overtaking tuberculosis, and Osler referred to pneumonia as the 'Captain of men and death."  (4)  Osler borrowed the term from John Bunyon (1628-1688) who became famous for writing the Pilgrims Progress.  Bunyon used the phrase to describe consumption (tuberculosis), which was a diseases most commonly associated with death in his day.

In 1928 Sir Alexander Fleming observed that colonies of the Bacterium Staphylococcus that he was growing in a colony were dissolving.  He later discovered the plates had been infested by a blue-green mold, and he determined it was this molt that was responsible for the bacteria dissolving.  He later grew the mold in its pure form and discovered that it killed many different kinds of bacteria. (5)

The mold he used was Peiciillium notatum.  The importance of this discovery was not known until 1939 when Howard Florey and Ernst Chain isolated the active ingredient and developed a powdered form of it.  (5)  Several Eurpean and American scientists worked together to work on a therapeutic medicine that could be used to treat bacterial infections.

By 1941 they had succeeded, and penicillin studies were performed.  In 1944 antibiotics were made available to treat allied soldiers wounded on the battlefield.

Incidence of pneumonia started to decline in 1937 due to improved medicine. So oxygen therapy, coupled with penicillin, helped decrease the rate of pneumonia deaths.  Yet cases of pneumonia continued to be prevalent. 

For example, operations weren't commonly performed in hospitals until the 1950s when effective aneasthetics and breathing machines were made available. In the 1960s and 1970s physicians noted the high incidence of pneumonia after operations -- particularly abdominal surgeries -- despite the use of antibiotics. Similar observations were noted among patients taking sedatives or pain relievers such as morphine.

Further study helped researchers determine the reason was because due to pain, or due to the sedatives,  these patients weren't taking deep enough breaths, and weren't adequately coughing.  This helped to create a breeding ground in the lungs for certain bacteria. Post operative pneumonia was learned to complicate treatment, prolong hospital stays, and even cause death.

To treat this, the incentive spirometer was invented.  The goal of this device was to encourage post operative patients to take deep breaths followed by a breath hold and a good cough.  It was also recommended that post operative patient get out of bed and start moving as soon as possible after surgery to prevent pneumonia. 

So the incidence of pneumonia took a sharp decline, and deaths likewise declined.  When a pneumonia vaccine hit the market in 1977 pneumonia rates declined a little more.  By 2000 a pneumonia vaccine became available for children, and this helped decline pneumonia deaths to its current level as the sixth leading cause of death.

Pneumonia is a malady that has been prevalent since the beginning of time.  Throughout the 20th century scientists found evidence of this in various Egyptian mummies from 1250-1000 B.C. that were shown to have pneumonia and other diseases of the lungs.  In one case of mummy pneumonia, the mummy was found to have a bacillus similar to the plague.

It's true that pneuomonia will continue to inflict people with diminished immune systems, such as the elderly and sick.  Yet with a growing plethera of medical knowledge, physicians have been able to greatly reduce the incidence of this disease, and in the process, prevent many deaths from the malady.

References:

1. "Leading Cause of Death, 1900-1998," http://www.cdc.gov/nchs/data/dvs/lead1900_98.pdf
2. Sturges, Octavius, "The Natural History and Relations of Pneumonia," London, 1876
3. "History of Pneumonia," The British Medical Journal,  Jan. 19, 1952, pages 156-158
4. Schmitt, Steven K., "Oral Therapy for Pneumonia:  Who, When, and With What?" editorial, Journal of Clinical Outcomes Management,  March, 1999, vol 6, No 3, pages 48-50
5. Bellis, Mary, "The History of Penicillin," http://inventors.about.com/od/pstartinventions/a/Penicillin.htm
6. Marrie, Thomas J, "Community Acquired Pneumonia," 2001, New York, chapter one by Jock Murray, "The Captain of Men and Death: The History of Pneumonia."
7. Auld, A.G., "The Pathological Histology of Bronchial Affections," The Lancet, Aug. 6, 1892, page 312
8. Allbutt, Clifford, ed, A System of Medicine, 1909, Toronto, chapter on "Lobar Pneumonia,"  by P.H. Pye-Smith, pages 191-205
9. Addison, Thomas, "A Collection of the published works of Thomas Addison," 1868, 
10. Auld, A.G., "Fibroid Pneumonia," The Lancet,  June 13, 1891, page 1308-1310
11. "Nikolai Fedorovich Gamaleia, The Free Dictionary by Farlex, http://encyclopedia2.thefreedictionary.com/Nikolai+Fedorovich+Gamaleia
12. Osler, William, "The Principles and Practice of Medicine," 1898, 3rd ed., New York
13. *Photo compliments of sciencephotolibrary.com

Asthma sympathy

In a way asthma is both a burden and a blessing.  It's a burden for obvious reasons.  It's a burden because you have to admit you have it and make the necessary adjustments in your lifestyle.  It's a burden because you have to admit you are not normal.

It's a blessing because when you're having trouble you realize how great a friends you have.  My coworkers refused to let me take the ER, which can be very taxing on most days.  They made me take the medical/ surgical floors and do just regular treatments.  

When I couldn't get into my doctor's office to see him, I caught up with my doctor and he made it so I was seen.  That's what I call your good neighborhood doctor.  Some people say he's not such a good doctor, but as far as I'm concerned he's a champ in my book.

Surely it's a burden that I had to take a week off from my workouts, but it's a blessing that my wife and kids were understanding and made it so I could take it easy for a while.  It actually got to the point I was getting bored. 

1810: The first PEP therapy, Incentive Spirometer x

Figure 1 -- Ramadge Iinhaling Pipe (1, page 93)

If you're a respiratory therapist in the 19th century -- if the profession existed as it does today -- chances were you'd be familiar with the Ramadge Inhaling Pipe.  It was the first device that acted both as an inhaler, PEP (Positive Expiratory Pressure) therapy, and Incentive Spirometer

The device was a pipe with hot tar stuffed into it that you inhaled for therapeutic means.  The tar, and the narrow diameter of the tube, provided resistance to inspiration and expiration, and this was supposed to provide "gymnastics" or "exercise" for tuberculosis patients.  

Samuel Sheldon Fitch in his 1847 book, "Six lectures on the uses of the lungs" (1, pages 91- 93) explains that the most common respiratory ailment during the 19th century was consumption, or what we now refer to as tuberculosis.  He believed it could be prevented by doing things that prevent too much air from leaving the lungs and causing the small, frail rib cage as seen with consumption.

He believed one of the things that could prevent the disease was asthma.  Why?  Because asthma is a disease that causes excessive air to remain in the chest, and this results in a large, expanding full chest (barrel chest), or the exact opposite effect as tuberculosis. 

So he believed asthma prevented tuberculosis, and one means of generating the effect of an "expanded chest" is to breatht to a device he invented that ultimately became known as the Ramadge Inhaling Pipe.

Truly it really wasn't a PEP valve, because the concept hadn't been though up yet. And truly it wasn't a spirometer, because there was no means to measure inhalation or exhalation volumes or pressures, yet it provided a similar effect to both those devices.

Ramadge was a student of Rene Laennec, who was the inventor of the stethoscope. Together they did extensive studies on tubverculosis and how to prevent it, and Laennec wrote about them in his "On Mediate Auscultation."  From their research Ramadge believed that so long as you took care of your asthma you would prevent tubercolosis.  This was the basis for Ramadge inventing the Ramadge Inhaling Pipe.

In his book, Laennec described Ramadge's discovery (1, 2):

"(That) having the patient breathe through a small opening or pipe much smaller, say 20 times smaller than the opening of the windpipe.  To effect this, he made an instrument then called an inhaling tube.  It was four feet long with an opening through it's whole length, provided with a mouth piece to go between the lips, and the patient sucked in, or inhaled the air as long as he could, and then through the same tube, blew it out again.  By this process the chest would rapidly enlarge.  Dr. Ramadge also made an inhaling tube a little like a whistle, with a valve in it so constructed that the air would go into the mouth and lungs through a much smaller opening.  The effect of which is, to allow the lungs to fill rapidly and without exhaustion of strength, and on leaving the lungs it is all passed through an opening not much larger than a knitting needle by which the air was slowly forced our of the lungs, and by this pressure the lungs were greatly expanded, and the air every where opened the chest in the largest manner."

Laennec recommended these tubes be made of gold, silver or at least wood so that they last long, and the patient can take the tube wherever he goes and can use it often to keep his lungs expanded and prevent consumption.  (1,2)

Incentive spirometers have advanced quite a bit through the years, and they are now generally used to exercise and open alveoli by patients who are bedridden, postoperative, or are on sedatives and pain relievers.  PEP therapy is quite the same, although the devices are now much more advanced.

References:

1. Fitch, Samuel Sheldon, "Six lectures on the uses of the lungs," 1847, New York, H. Carlisle, pages 91-93, 
2. Laennec, Rene, "On Mediate Auscultation," 1827, London, T and G Underwood.  The above quotes are from Fitch's book, although they can also be found in this reference

The asthma conundrum

My present asthma conundrum gave me a good idea for an asthma post for healthcentral, and I sent it in to be published.  It's basically a letter to my fellow asthmatics, a reminder of sorts, that if you are having asthma symptoms it's OK to take a day off.  

It almost sounded like a corny idea, but I sent it in anyway.  I have no idea when it will be published nor that it will.

I figured I was a credible source for such advice because that's exactly what I had to do these past two weeks.  Usually when I get the crud I just tough it out, but for some reason I sensed a downward trend.  Instead of getting better every day I was getting worse.  

I didn't want to call in sick to work, but I had to.  I didn't want to call my doctor, but I had to.  Most important, I didn't want to take time off my workouts.  I had been doing the body for life since January and had lost 20 pounds.  I wanted to keep it going.  but I had to quit.  I had to.  

I know asthma experts, including myself, say you can live a normal life with asthma.  But you and I know that's not necessarily true.  You can live a "relatively" normal life, but you can't live a normal life as someone who didn't have asthma would.

I suppose "normal" would vary from one person to another.  Normal to me is not going to hunting camp with every other guy.  Normal to me is making my poor wife cut the grass.  Normal for me is letting my wife cleaning the basement while I do the dishes.  

Normal for me is suffering from heartburn all day because I had to be put on prednisone and it always gives me heartburn.  I think it gives me heartburn more so because prednisone makes me want to eat all the time.  And then when I give in and eat I get heartburn.  

However, thanks to my giving in and taking time off, and thanks to prednisone, my asthma is better.  I didn't have to break my streak of not needing an ER.  That, I think, is a good thing.  And, most important, I'm still alive.  I'm still able to get hugs and kisses from my kids.  I'm still able to be a slave to my kids, if you know what I mean.

1941: Dr. Christie defines emphysema and how to treat it

Ronald V. Christie was considered to be the most renowned expert on emphysema in the 1930s and 1940s.  He defined the disease pretty much as we know it today, and then he provided various treatment recommendations that he determined would help these patients during episodes of acute dyspnea.

In his article "Emphysema of the lungs:  part II," (British Medical Journal, Jan. 29, 1944, pages 143-146) he describes how ephedrine was the best medicine to relieve dyspnea.  He noted the following:

"Although there may be no evidence of bronchospasm or resistance to respiration, the administration of ephedrine not infrequently relieves the dyspnoea of emphysema.  A possible explanation of this effect is that the bronchioles leading to the over-distended air sacs and bullae are less capable of changes in calibre than those leading to healthier parts of the lung; bronchospasm, although not clinically manifest, would in this case increase the proportion of the inspired air deflected to these useless parts of the lung, and the relief of bronchospasm with ephedrine would improve the efficiency of ventilation and thus relieve dyspnoea."

It's interesting that he wrote this considering I have often wondered myself why a bronchodilator would benefit emphysema patients.  It's not like a bronchodilator would help a patient regrow lung tissue.  Yet what he wrote makes sense, and other more recent studies have confirmed what he suggested (sort of).

He briefly mentioned surgical procedures to deflate parts of the lungs.  He was also among the first to describe "respiratory exercises designed to teach the patient to deflate the lung and to increase the use of the diaphragm."

During the end stages of the disease when heart failure occurs he recommends oxygen.  Back then oxygen tanks had to be hauled into the hospital room by the nurse.  He explained that "recovery from heart failure in emphysema was uncommon."  However, he explained a case in which supplemental oxygen could extend the life of a "moribund" patient for a little while.

1679, 1814: The terms emphysema and bronchitis are coined

The 42-year-old Alaskan woman sat by the crackling fire 1,600 years before the birth of Christ.  She was severely winded after just a short walk with the children.  Her chest heaved up and down, occasionally interrupted by a dry, hacking, painful cough.

"I can no longer do  this," she decided, working hard to stop the tears.  The children stood around her silent and concerned.  These episodes were happening more frequently now, so often that she could barely stand it.  "I'm fine," she said.  It was a lie.

Looking into our prism we can see the woman obviously suffered from Cronic Obstructive Pulmonary Disease (COPD), although back then the disease she suffered from was poorly understood. In Alaska there may have been no treatment at all other than rest.

We know she probably acquired the disease gradually over time as she continued to inhale smoke from the same fires she used to cook food for the children and their parents.  We know she probably died slowly from lack of oxygen.

Nearly 1,600 years later, a Greek physician named Hippocrates described asthma for the medical community, describing it as dyspnea, or shortness of breath.  He was not aware of different causes of dyspnea, so they were all included under his umbrella term asthma.

Yet somewhere, tucked nicely under this umbrella, were patients who had inhaled some microscopic substances, perhaps a chemical, that caused changes of some airway tissue and destruction of others.  The end result were diseases we now refer to as chronic bronchitis and emphysema, and that we lump under the umbrella term chronic obstructive pulmonary disease.

It would be another 2,000 years before emphysema would be described around 1650 A.D.  The 17th century was well known as a time when physicians were performing autopsies in order to match symptoms observed in life with changes that occurred within the body.

Emphysema became a term that would be used to describe lungs that were larger than normal due to the fact they held abnormal amounts of air.  The term would come from the Greek term physe, which means "to blow into."  They did not, however, understand why the lungs had extra air blown into them, so this resulted in much speculation.

Theophile Bonet (1620-1689)

So it was in the year 1679  that a Swiss physician named Theophile Bonet performed over 3,000 autopsies on patients he followed, and was among the first to describe emphysema as a medical condition of "voluminous lungs" in his book Sepulchretum. (2) (3) (4)

Giovanni Morgagni (1682-1771) wrote how he respected the works of Bonet, and he himself described several cases of "turgid" lungs in his classic work "On the seats and causes of disease."

In 1784 Dr. Samuel Johnson was a well known physician, and he also became well known for his breathing trouble. He was thought to have suffered from asthma from birth, and later he was determined to have died of fibrosis of the lungs.  Although from autopsy results future historians have concluded that what he died of was emphysema and cor pulmonale and not asthma.  (6)

Dr. James Arthur Wilson was only 19 when he performed the autopsy on Dr. Johnson, and he described the following:

Dr. Samuel Johnson

"On opening into the cavity of the chest, the chest did not collapse as they usually do when the air is admitted, but remained distended, as they had lost the power of contraction; the air cells on the surface of the lungs were also very much enlarged... the heart was exceedingly large and strong."

In 1721 Ruysh provided the first detailed description of emphysema coupled with pictures.

Matthew Ballie was a prominent British physician who inherited his father's anatomy school in 1783.  Throughout his career he studied the bodies of diseased patients, including some specimens handed down to him, such as the lungs of Dr. Samuel Johnson.

Matthew Ballie (1761-1823)

In 1799 and 1807, Ballie  described emphysema with detailed pictures.  He described the condition as "enlarged air spaces" in the lungs, and lungs that did not collapse.

He published a book in 1793, "The Morbid Anatomy of Some of the Most Important Parts of the Human Body." It's believed to be the first book on pathology.

He described the lungs of emphysema patients, which included the following description of Dr. Johnson's lungs:

"The lungs are sometimes, though I believe rarely, formed into pretty large cells to resemble the lungs of an amphibious animal. Of this I have seen three instances. It is not improbable that this accumulation (of air) may break down two or three contiguous cells into one, thereby, form a cell of very large size." (5, page 2)

Charles Badham (1813-1884)

In 1814 British Physician Charles Badham became the first to use the term "bronchitis" to denote "inflammatory changes in the mucous membrane." (9?)

Bronchitis would soon "supercede" the term chronic catahrr when referring to chronic inflammation of the respiratory tract that resulted in a chronic cough and the spitting up of yellow or otherwise colorful phlegm.   (9)

Catahrr was a blanket term used to describe swelling of mucus membranes that resulted in excessive secretions. Throughout the remainder of the 19th century, catahr would continue to be used to describe inflammation of the nasal passages. Another term that caught on around the 1820s was or hay fever.  The terms allergy and colds would not be coined for another 80-plus years. (9)

Laennec accurately described emphysema (13)

In 1821 Dr. Rene Laennec -- known as the father of chest medicine in part due to his invention of the stethescope -- accurately described both emphysema and bronchitis as related conditions. (3)

He defined bronchitis as "chronic mucous catahrr," and "filled with mucous fluid."  (3)

He defined emphysema as "lungs (that) do not collapse.  But they fill up the cavity completely on each side of the heart."  (3)

Laennec became the first to describe emphysema due to aging, and he was the first to define emphysema as tissue damage in the peripheral air passages.  He further defined emphysema as a breakdown of tissue in the parynchema of the lungs as opposed to air trapped in the alveoli due to an obstruction such as occurs in asthma and bronchitis.

In this way, it was Laennec who became the first to distinguish chronic bronchitis and emphysema as separate entities from asthma.  He was the first to speculate that they ought to be extricated from the umbrella term asthma, to become disease entities of their own with their own treatments.

William Stokes (1804-1878)

In 1837 Dr. William Stokes became the first to use the term "chronic bronchitis" in his book "The Diagnosis and Treatment of Diseases of the Chest."  He defined bronchitis as "inflammation of the mucous membrane," and that this condition may give rise to "dilations of the air cells and tubes, and to pulmonary emphysema."  (8, page 45)

He also said bronchitis is evident in nearly all diseases of the lungs.  In noting this, he was drawing a similarity with bronchitis, pneumonia and asthma.

Like Laennec, Stokes was among the first to explain the relationship between chronic bronchitis and emphysema, and believed bronchitis lead to emphysema. He was also the first to describe different types of sputum, such as mucoid and mucopurulent.  (1, page 86).

He also mentioned increased secretions and chronic cough as part of the condition.

John Hutchinson's spirometer

In 1846 John Hutchinson invented the spirometer.  While he believed his device was limited in its purpose, it would become the perfect device for diagnosing and treating many diseases of the lungs.

His device was limited in that it could only measure vital capacity, which is the total amount of air that can possibly be exhaled. Yet this measurement would become useful in helping a physician distinguish between bronchitis, emphysema and asthma.

In 1861 Dr. Henry Hyde Salter described in his book, "On Asthma: It's Pathology and Treatment," that he had never performed an autopsy on an asthmatic when he didn't see evidence of emhysema.  Other doctors would make similar statements.  Salter also described the barrel chest common with asthmatic children.

However, Salter and other physicians of his day didn't have the ability to differentiate from true asthma as we know it today and true emphysema and chronic bronchitis.  Yet to their credit, emphysema was a rare disease until after WWI when cigarette smoking became common place.

By 1870 emphysema and chronic bronchitis were clearly noted as related diseases, and descriptions were present regarding the breakdown of lung tissue that resulted in progression of the disease that resulted in hyperinflation of the lungs. 

In 1885 a physician by the name of Mendelssohn "stated that he had met many persons dying from tuberculosis whose symptoms never showed themselves until they worked with coal dust and smoke." (10)

He was therefore among the first to observe the relationship between environmental inhalents and lung disease.

By 1898 the air sacs in the lungs were no longer called simply "cells," they were referred to as alveoli in books and magazines such as The Clinical Review. (12)

Emphysema was now clearly defined as "dilation of the alveoli of the lungs and atrophy of the alveolar walls."  (12)

Doctors such as Joseph M. Patton started differentiating overdistention of alveoli due to obstructive diseases such as asthma with excessive air in the lungs due to tissue "atrophy." (12)

By 1930 a plethera of descriptions of the conditions started to show up.  One physician described enlarged goblet cells in bronchitic lungs that resulted in increased secretions.   Another performed tests that showed airflow limitations in patients with emphysema, and explained that this was due to lost of lung elasticity.

By the 1930s emphysema was clearly understood to be a disease of loss of elasticity of the lungs that results in enlargement of the thoracic cage, which resulted in the appearance of a barrel chest, such as what was previously described by Salter. (11)

Because the chest was already expanded, the regular muscles of inspiration would be of little use in drawing in more air.  So, in order to take a deeper breath, the patient would have to make a conscious effort and use his accessory muscles.  At first these muscles would become sore, although over time, as they were used with increased frequency, they would become strong, and therefore hypertrophied, and would therefore be no longer sore.  (11)

In 1933 Ronald V. Christie, a professor of medicine at the University of London who specialized in emphysema, performed a study that showed the relationship between loss of lung elasticity and airflow limitations.  (1, page 87) 

With breakdown of tissue of the alveolar walls excess air enters this space and the result is overdistention.  This can also result in bulla, which are large areas of tissue breakdown and air trapping, meaning this entire portion of the lung will not be involved in the process of ventilation.  The end result is increased dyspnea.

In 1944 Christis suggested, that because the lungs were always expanded due to loss of elastic recoil, expiration would have to be passive.  He said:

"With loss of elasticity there must be loss of elastic recoil, so that if the lung is to be deflated it has to be squeezed. The respiratory musculature was not built for this task, and the intercostals have to be assisted by the accessory muscles on expiration: the muscles of the abdominal wall can often be felt to contract on expiration, which is prolonged as it is in other conditions, such as asthma and tracheal obstruction, in which the lungs have to be compressed by an active muscular effort. With so extensive an impairment of both inspiration and expiration it is not surprising that the vital capacity and chest expansion are reduced." (11)

In other words, he is describing the conscious use of accessory muscles.

He describes lungsounds as faint except for in the bases where they may appear to be absent.  Diagnosis could be made by observation of the physical signs, such as a barrel chest, vital capacity measurements with spirometry, and obvious dyspnea on exertion not attributable to other conditions.

He also suggested diagnosis should be made based on signs of chronic cough or asthma, meaning dyspnea.

By the 1950s physicians had learned so much about the lungs that they pretty much wiped the slate clean and redescribed both emphysema and chronic bronchitis for the medical community.

Experts determined there were various disease processes that could result in excessive air in the chest or overdistention of the alveoli such as acute asthma or chronic bronchitis. This "overdistention" was no longer considered emphysema. True emphysema would now be considered air in the interstitial spaces due to breakdown of parychemal lung tissue such as the pores of Kahn and the walls of the alveoli. 

Air trapping in asthmatics was determined to be completely reversible, and air trapping in chronic bronchitis patient only partially reversible.  As with emphysema, both may result in a barrel chest, although a barrel chest in asthma is only temporary, and the barrel chest in emphysema is chronic.

During the 1960s and 1970s pulmonary function testing was used with increased frequency to study lung diseases, and it was during this era that the term FEV1 was first used to measure expiratory flow. This is a test result that could not be faked, and that could easily be used to differentiate asthma from chronic bronchitis, emphysema, and other lung diseases.

By the 1980s pulmonary function testing would become commonplace in diagnosing COPD, with the measurement of FEV1 being the most significant measurement.

While physicians like Dr. Wilson keenly observed the large heart in those suffering from lung diseases, by the 1980s physicians understand that diseases like chronic bronchitis and emphysema, now lumped under the umbrella term COPD, became still.

In an effort to force blood through stiff lungs, the right heart is overworked and becomes enlarged over time, resulting in a condition called cor pulmonale. Physicians now understood that when this occurred, the disease was in it's final stages, or end stages.

It was at time time dyspnea would become increasingly worse, and might be caused by infections such as pneumonia in the lungs, or it might be caused by heart failure.

In 1972 the mummy of a 1,600 year old woman was discovered in Alaska. The woman was found to have evidence of emphysema, and this may be the oldest reported case of COPD.  (1, page 85).

1. Qutayba Hamid, Joanne Shannon, James Martin, "Physiologic Basis of Respiratory Disease," 2005, Montreal, page 85-99
2. Bhatia, K. Sujata, "Biomaterials for Clinical Application," 2010, London, page 100
3. Petty, Thomas L, "The History of COPD,"Int. J. Chron. Obstruct. Pulmon. Dis., 2006, March; 1(1): 3-14
4. Crellin, J. M.D., "Selected Items from the history of pathology," Am J Pathol. 1980 January; 98(1): 212.
5. Thurlbeck, Wright, "Thurlbeck's Chronic Airflow Obstruction," 1999, Canada, pages 1-6
6. Reich, Jerome M, "Convulsion of the lung: an historical analysis of the cause of Dr. Johnson's fatal emphysema," Journal of the Royal Society of Medicine, Vol. 87, December, 1984, page
7. Laennec, Rene, "Treaties of the diseases of the chest," 1821
8. Stokes, William, "The Diagnosis and Treatment of Diseases of the Chest," 1837, Dublin
9. Gee, Samuel, "Bronchitis, Pulmonary Emphysema and Asthma, " The Lancet, March 18, 1899, page 51
10. Klotz, Oskar, Wm. Charles White, ed., "Papers on the Influence of Smoke on Health,"  Bulletin #9, 1914, page 36
11. Christie, Ronald V, "Emphysema of the Lungs: Part II, British Medical Journal, Jan. 29, 1944, page 143-146
12. Cleveland, Geo. Henry, "The Clinical Review: AJournal of Practical Medicine and Surgery," Vol. VIII, April-Sept. 1898, Chicago.

Photos:  

1. http://library.medicine.yale.edu/about/adopt/laennec