1850: Asthma as a disease of the mind -- rewrote

So asthma is all in your head.  Any exposure to strong smells, dust, and anxious situations causes you to miss time with the guys.  It forces you to spend more time with your mother.  You are thus dubbed to have a nervous disorder.

While the idea was mentioned by ancient asthma experts, it was once again brought to the attention of the medical community in 1850 by a famous British doctor by the name of Dr. Robert Bentley Todd.  He wrote an article for the Medical Gazette in December of 1850, as described by Dr. Henry Hyde Salter in his book, "On Asthma." (1)

Salter explains how Todd really wasn't the first to come of with the idea of nervous asthma, yet he was the first to take the idea seriously, and kind of got the ball rolling that, yes indeed, asthma was a psychosomatic disorder.

In his article, Dr. Todd wrote that asthma is caused by a "poisoning" of the nervous system as it pertains to the respiratory system. The offending "poison," or "peccant matter, was referred to by Todd as  the materies morbi. The result is a "spurious and morbid sense of want of breath," writes Salter about Todd's theory.  "This breathlessness is the first step in the morbid phenomena. That it may have no real objective cause in the lungs themselves; that bronchospasm is a accompaniment not a cause, of the dyspnea of asthma; and that you may have asthma without any bronchial contraction whatever." (1)

Todd describes that the signs of asthma (particularly bronchospasm and the resulting dyspnea) are not what asthma is, but merely a symptom of asthma. Asthma is the poisoning of the nervous system.

The idea here is that even if you are not having an exacerbation of asthma, you still have asthma. Todd describes that asthma is a permanent condition of the mind. It is always there, yet it only shows itself some of the time.

In this way asthma is not unlike other conditions that "irritate" the nervous system to cause prominent symptoms, such as:

• Gout (Sudden joint pain that eventually goes away)
• Epilepsy (Seizure that eventually goes away)
• Asthma (Shortness of breath that eventually goes away)

Dr. Salter disagreed with Dr. Todd in Todd's assumption that asthma could occur without bronchospasm.  Salter believed simply the fact you can hear wheezes is a sign that bronchospasm occurs, because when you narrow pipes it makes a similar noice. (Salter, page 19)

Yet Salter agreed with Dr. Todd in his assertion that asthma is nervous.  Salter later went on to prove, or attempt to prove, why he suspected as much.

The following is Salter's evidence that asthma was nervous in origin:

• Fatigue and mental emotion bring about an attack
• Remedies that appeal to the nervous system allay an attack, such as stramonium, antimony and chloriform.  
• The periodicity of asthma.  It goes away and comes back without warning by recurrence of hay fever, indigestion after dinner, expectoration after a good nights sleep, etc.  
• Symptoms of asthma, such as clear urine (nervous urine), nervous headache, drowsiness, and  an attack after laughter or animation.  These are similar to hysteria and epilepsy.
• No organic change in the lungs during or following an attack.  Post mortem exam of asthmatics shows no organic changes, or damage, to the lungs.  They are essentially normal.
• Asthma is muscular in that it is caused by muscular fibre that spasm and squeeze the air passages of the lungs.  Muscular disorders like this are always nervous as the nerves are connected with the mind (2)

Salter's writings on asthma originally appeared in magzines, and was so well received he was encouraged to publish his works in a book.  He did such a good job by his writings that his ideas about the causes of asthma were well respected by the medical community.  

His evidence that asthma was nervous continued to hold sway in the medical community until it was scientifically disproved in the 1950s.  Yet it was 30 years after it was disproved -- like in teh 1980s -- that asthma experts finally gave up the idea that asthma was nervous

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Further reading:

• Click here for more asthma history.
• Good article about asthma as a psychosomatic disorder

References:

• Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment," 1882, London, pages 8-
• Salter, ibid, pages 13-16

1600s: Asthma could get you absolved from crimes

How would you like it if someone said to you:  "You're asthma is all in your head?"  If you're like me you wouldn't take it too well.  On the other hand, if having asthma could get you off the hook for a crime you committed, perhaps you'd think differently.

Asthma experts in the ancient world realized early on that life was different for those inflicted with asthma or allergies.  Consider the following:

• A boy rides a horse and has an asthma attack
• A boy wrestling in dry dirt has an asthma attack
• A boy is learning to dig trenches and has an asthma attack
• A boy learning to ride a chariot has an asthma attack

Obviously the boy will not be fit for battle.  This boy will be forced to stay at home with his mother instead of hanging out with the men.  He will be deemed as feminine by his peers, an outcast, mentally deranged, weak, and useless.  

Boys like this became the subject of some of the world's greatest minds.  Hippocrates, Galen,  Ballonius*, Felix Platerus**, and Avicenna*** all mentioned a relationship between asthma and the nerves of the brain.  (2)

It was clearly evident that asthma was a mental disorder.  And this surely didn't help the poor asthmatic boy who just wanted to fit in; who just wanted to be one of the guys.  

Asthma was clearly a nervous disorder:

Around 400 B.C. Hippocrates, or at least one of the Hippocratic writers, wrote a convincing text that linked asthma with an increase in the humor phlegm.  This caused a disorder of the mind that resulted in asthma, or gasping breaths.  

In the Greco-Roman era asthma was linked with the nerves of the mind.  In his 1933 report in the Proceedings of the Royal Society of Medicine, "The History of Bronchial Asthma and Allergy," Stoikland described how Galen mentioned in his experiments on monkeys that "cutting of the medulla spinalis, the respiration and the voice are affected.  Ballonius, speaking about a patient with renal calculus and dyspnoea, says that there is a 'nervulus' (small nerve) from the sixth pair which penetrates the diaphragm and goes to the kidneys and this may also cause dyspnoea." (2)

You must consider here that during this time asthma was not defined as we know it today.  Back then asthma was any disease other than pneumonia and tuberculosis that caused dyspnea. Asthma was a complicated disease that was poorly understood.  Those who studied it were prone to speculate as to it's cause, effect and treatment.  

Maimonides (1138-1204) may have been the first to define psychosomatic medicine (the mind causes diseases) when he wrote how a patient who is "mentally agitated" caused his physical well-being to suffer and eventually he becomes physically ill. 

Maimonaides also explained that "gaiety and joy gladden the heart, and stimulate the blood and mental activity.  Excessive indulgence in the pursuit of pleasure, however, is injurious to one's health.  The avoidance of illness induced by such excesses is by conducting oneself according to ethical and moral principles."

Felix platerus (1536-1614) was among the first to advocate the treatment of mental patients. He believed that "an obstruction in the small pulmonary arteries is the cause of asthma.  But he mentions also that the bigger nerves from the dorsal medulla, when disturbed by defluxions, occassion dyspnoea, e.g., in asthmatics.  He observed the attack when nothing abnormal in the lungs could be found."

Jean Baptiste van Helmont (1577-1644) and Thomas Willis (1621-1675) are believed by many asthma historians to be the first to write about asthma specifically as a nervous disorder. While others obviously noted the link, Willis is most often given credit for starting physicians thinking along the notion that asthma was nervous -- he launched the idea in the minds of asthma experts seriously attempting to define this disease.

Willis described asthma in this way (2): 

"Whatsoever makes the blood to boil or raises it to an effervescence, as violent motion of the body, or mind, the drinking of wine, venery, excess of external cold or heat..., any great change of the air or of the year, slightest errors, a thousand other occasions, doth cause asthmatical assault to such as are predisposed.... This kind of dyspnoea, merely convulsive, is excited by reason of the pneumnonoc nerves... It is not to be doubted that the fits of asthma wholly depend on convulsive matter being fallen into the nerves, serving to the stretching forth of the lungs.... Soon the asthmatic attack is finished, no signs of abnormal disposition of the lungs can be found.  Severe attacks of asthma may occur without any notable fault of the lungs."

Van Helmont described many examples that prove psychotic factors can lead to asthma.  He wrote about women who had attacks of the asthma as a result of exposure to flowers.  He describe one situation where a man was pressured to speak and he refused.  The man was so stressed that he had an asthmatic attack and died.  This was all attributable to psychotic or nervous asthma.(2)

John Floyer (1649-1734) likewise followed the ideas of van Helmont and Willis.  William Cullen (1710-90) believed asthma was a disease of airway constriction of the muscular fibres that wrap around the lungs and also that it was triggered by psychological factors.  Irritation of the mind by certain odors, smoke, and dust trigger the asthmatic response. 
So there was plenty of evidence to link asthma with the mind.  Yet it truly wasn't until the 17th century A.D. (the 1600s) that asthmatics caught a break. They still may have been mocked by society, but at least something went their way.

A big break for asthmatics:

Paulo Zacchia (1584-1659) was a Roman physician and a personal physician to the Pope Innocent X and Alexander VII  (3).  He published "Quaestiones Medicolegales" in 1621.  It was published as 11 volumes between 1621 and 1661 and "was considered an important landmark in the history of forensic medicine." (1)  It was mainly a book with legal information about wounds and "jurisprudence about insanity."  (3) 

The book displayed an up to date medical advice to be used in legal cases that considered the latest wisdom of science, which included knowledge that there was a difference between adult and fetal lungs, and acknowledged wisdom about the circulation of the blood.  This was a first of its kind legal journal that provided legal advice at a time when science was in its infancy

Paul Ammann's (1634-91) was a man of "acute mind and extensive learning, but a restless and irritable disposition led him to engage too much in controversy."  For instance, in a time where the writings of Hippocrates and Galen were worshiped by the medical community he "boldly" attacked the systems of medicine they created. (4)

Amman's book "Medicina Critica" was published in 1670 and was a compilation of medico-legal cases decided by the medical facility of Leipzig.  (1) These men were provided with the evidence that asthma was a nervous condition (some of which you read above) and perhaps had to defend asthmatic criminals in a court of Roman law.

Zacchia and Amman both believed that "as fear can provoke asthma, the asthmatics were absolved from criminal inquiry,"  according to E. Stolkind in his article "  In this way, it was common for asthmatics to be kept out of stressful, and dirty prisons as this might provoke an attack that might provoke a lawsuit. 

As we continue on in our quest to learn about the history of asthma you will find many references of asthma as a nervous disorder.  We'll pick this theme back up as we travel to the 19th century and meet Dr. Todd an Dr. Salter.

Click here for more asthma history.

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*Ballonius is a Parisian physician who lived 1538-1616 and is credited for coming up with the term rheumatism to explain vague pains in the external parts (5). To learn more about Hippocrates and Galen click on the links above. ** Felix Platerus was one of the first ot advocate the treatment of mental patients. (2, page 30)  *** Avicenna was a Muslim physician and philosopher who lived 980 A.D. 1034.  He wrote 150 treaties on philosophy and about 40 on medicine.  His most famous book was The Book of Healing which was a standard medical text for hundreds of years.

References:

1. Clark, Michael, Catherine Crawford, "Legal Medicine in History," 1994, page 105
2. Stolkind, E., "The History of Bronchial Asthma and Allergy",  (Proceedings of the Royal Society of Medicine, 1933, Vol. 26, part 2, page 1120; 36
3. Fielding, Hudson Garrison, "An introduction to the history of medicine," 1922, London, page 272
4. "Amman Paul," Encyclopedia Britannica of a dictonary or arts, science, and miscellaneous literature," 1842, 7th ed., vol. 2, part 2, page 657
5. The Massachusettes Medical Society, New Englang Surgical Society, Boston Medical and Surgical Journal, "Rheumatisms and Pseudo Rheumatisms," Vol. CXIII, 185, July-Dec., page 38

1810: Bree's Symptoms of Asthma

The following are the symptoms of asthma as described by Robert Bree in his book "A Practical Inquiry into Disordered Respiration Distinguishing the Species of Convulsive Asthma, their Causes and Indication for a Cure."  It was written in 1810. 

Note:  You must understand that Bree's undestanding of asthma was very puerile compared to our modern definition.  Much of his descriptions and theories on asthma are based on observation and personal experience with the disease as opposed to scientific facts.  However, some facts were available at this time and he used this information to support his opinions.  This was not uncommon for his day and age. 

Anxiety:  Owing to the difficulty attending the efforts of nature to removing an irritating offense.

Itching of the skin of breast and neck:  This sometimes precedes the violence of the fit and declines as agony of the fit decreases. This may be an effect of sympathy with the lungs and first passages. Irritating matter in the stomach is the probable cause of this symptoms.  Another cause may be the difficulty to which venous blood is returned to the heart

Perception of heat:  You feel like you have a fever, but you don't. 

Great desire of cool air:  Probably occassioned by a desire for oxygen, as you feel the means of obtaining it is increased by fresh air.

Closeness:  Areteaus wrote:  "The patient loves walking in the open air, with his mouth open, and is dissatisfied with the largest house, which seems to small to breathe in."

Dyspepsia:  (Upset stomach)  Always precedes periodic asthma.  This causes flatulence of the stomach and bowels and pain over the head and eyes and sleepiness.

The attack of the paraxysm in the night:  By concentrating, and by sacrificing sleep by staining up late and sitting in a recliner instead of the bed, this can often be avoided. 

Diabetes:  By this I think he's referring to the need to pee a lot during an asthma attack. He says this is common, although it provides little relief to the asthmatic.  He gives a few reasons, none of which make any sense.  Such as in the case of hysteric asthma, he says the kidneys may be relaxed due to sudden passions of the mind.  He says the kidneys receive nerves from the intercostals, and there is likewise a strong association between the lungs, kidneys, and stomach.  May also be linked to edema, swelling of the ankles and legs.

The straightness of the breast:  He supposes that this makes it easier for the exchange of air when the air sacs are filled with secretions, which is often the case in asthma.  The rest of his several paragraphs describing this are simply meaningless poppycock.

Intermitting pulse:  John Floyer attriutes this to constriction of the arteries, by circumvolving nerves, may more probably proceed from this condition of the heart.  It may also be cauesd by dyspepsia because of the strong relationship between the stomach and the heart. 

Spitting of black mucus:  He believes the coloring agent in the sputum to be carbon in the blood, which in the healthy person was exhaled

The pulse is generally feeble: 

Urine is pale and copious: 

Sleepiness: 

Belly seldom regular:  Constiation may alternate with diarrhea, and may be attributed to dyspepsia (upset stomach). There is remarkable action of the abdominal muscles and all the muscles  used to discharge faeces.  And he flatters himself that evacuation of such will provide breathing relief.

The habit of the asthmatic is generally cold:  The temperature will be lower than normal. 

The mind is impatient:  Not only does Bree write this as a symptom, he adds, "...and he suffers much from opposition to his method of management in his own case."  After several episodes of asthma he learns methods of comforting and satisfying himself, but help from others is often received with anxiety.  He becomes irritable during the fits, "and, with difficulty refrains his disposition to petulence." 

Generosity:  Bree notes the following interesting fact:  "It may be observed generally as a fact, that the mind of an asthmatics is more susceptible of generous and grateful feelings than that of any other invalid, subject to a chronical disease equally obstinate."  Emphasis added by me. 

Respirations more numerous during asthma attack:  They never exceed 30 without a considerable increase in pulse.  Bree recognized this is in general opposition to Floyer

References:

• Bree, Robert, "A Practical Inquiry into Disordered Respiration Distinguishing the Species of Convulsive Asthma, their Causes and Indication for a Cure," 1810, London, pages 117-140, Section IX

x 1887-1973: Frances M. Rackemann redefines asthma

Frances Rackemann

The year 1901 was the dawn of modern asthma wisdom and treatment. This was a year that saw the introduction of epinephrine and ephedrine. It was also the year that a young man named Francis Milton Rackemann graduated from Harvard College at the age of 14.  He would grow to become the greatest asthma and allergy expert of the 20th century.

In a memorial tribute to his friend, Dr. Walter S. Burrage explained that Dr. Rackeman was born in 1887, and then, after graduating from college, a series of coincidences lead to him becoming an allergist.

First, he followed his cousin to Harvard where he was completing his registration to medical school on the last day. After his cousin was done, the Registrar turned to Rackemann and said, "How about registering yourself? Just mail us a copy of your college diploma and turn up tomorrow at nine o'clock for the first class." Rackemann did both, and four years later he graduated cum laude.

Second, in 1914 and 1915 he worked with Warfield T. Longscope doing research on anaphylaxis. The two would write a series of papers about allergies. This experience catapulted Rackeman's career as an allergist, and he would go on to write over 175 papers on allergies. (7)

There were two popular views on asthma at this time. One was that asthma was a nervous condition, and treating it was as simple as soothing the mind of the patient. The second was that asthma was an allergic condition and that curing it was as simple as finding the right protein to inject into the patient.

Rackeman would write several papers refining the definition of asthma.  The most significant was a report on a study of 150 asthma patients in 1918:  "A Clinical Study of One Hundred and Fifty Cases of Bronchial Asthma."  Another was a paper he wrote in 1969 called, "Nervous Factors in Asthma."

Rackeman believed asthma was a symptom more so than a disease. He also believed that not all asthma could be defined as allergic, and therefore, in his 1918 paper, he categorized most asthma cases as either extrinsic or intrinsic.

Extrinsic asthma is when an asthmatic has a hypersensitivity to a protein in foreign objects, or things that are outside the human body.  Their bodies develop proteins (later identified as IgE antibodies) to these substances, and repeated exposure to these foreign proteins would cause the allergic/ asthma responses.   It's associated with hay fever (allergic rhinitis) and atopic dermatitis (eczema). (3)

He described extrinsic asthma as being more often associated with childhood-onset asthma, and generally presents prior to the age of 12. It effects more boys than girls. Today, it's often referred to as allergic or atopic asthma, and has a greater tendency to be hereditary.

The diagnosis of extrinsic asthma may be made by allergy skin testing. For the treatment of extrinsic asthma he recommended allergy shots to make the patient less sensitive to the proteins in that substance. For example, for a pollen allergy, "treatment with an extract of the specific pollen will relieve the hay fever and the asthma often entirely."

Although, he did mention that desensitization, or immunotherapy as it's often called, does not work for all patients. For example, he suggested that, for those asthmatics allergic to horses, injecting these patients with the proteins of horses does not always prevent the allergic response of those patients to horses.  (3)

Instinsic asthma would cover all those cases of asthma not attributable to allergies, such as asthma caused by sinus infections, chronic sinusitis, nasal polyps, teeth infections, gum infections, throat infections (croup), acute bronchitis, colds, kidney failure (kidney asthma), heart failure (cardiac asthma), gastrointestinal irritation, etc.  It usually effects adults more so than children, and is more likely to be chronic than extrinsic asthma. 

For the treatment of instrinsic asthma the remedy would be fixing the causative agent.  For example, if acute bronchitis is the cause, then the remedy would be to resolve the bronchitis.

However, he wrote that "the treatment of instinsic asthma is far from satisfactory.  Local treatment of the nose, throat and teeth has been long considered important.  The removal of nasal polypi, the drainage of sinuses and the extraction of teeth will all relieve the asthma.  This relief, however, rarely amounts to a cure and even if very marked is rarely permanent.  The fact that many patients have spontaneous intervals of freedom from asthma which last for moths or years, makes the results of any treatment difficult of interpretation."

He also discussed the idea of vaccines to prevent bronchial infections, yet, he wrote, "from these cases must be left for some future time."

Rackeman explained that while asthma may be distinguished by extrinsic and intrinsic, the general symptoms of the disease are very similar.  It's not possible to distinguish between extrinsic and intrinsic by performing a pulmonary function test (PFT), however PFT testing will help a doctor diagnose asthma.  (3)

In 1927 he wrote the chapter on asthma and allergies for the first edition of Cecil's A Textbook of Medicine, a medical textbook still used to this day.  He explained the most up to date wisdom of these diseases at this time, and listed several allergens such as dust, fumes, foods and animal dander.

He also mentioned that most asthma cases were associated with increased eosinophils in the blood and sputum, including Charcot/ Leyden Crystals. (4, page 21)

He also supported the 19th century theory that asthma was a nervous condition. However, while he supported the nervous theory, he did not support the age old idea that a nervous condition, such as anxiety or stress, explained all cases of asthma.

He described this in his 1969 paper, "Nervous Factors in Asthma." He explained that to diagnose all asthma as nervous would result in missing the real cause, which may be an allergy to a cat or a pillow or ragweed pollen.

He explained that some cases of asthma are mainly nervous, and most of the time this involves intrinsic asthmatics.  He also explained how desensitization shots or skin testing may have no other effect that to "impress the patient and show that something is real and being done." (8)

Rackeman believed that the best treatment could be provided when the physician worked with the patient.  For 33 years he set up his general practice at his home, and often his family members had to shuffle through patients to get to their bedrooms.  He would also often visit his patients at their homes, and at times walk away "bandishing a guilty feather pillow." (7)

He was likewise friendly with his students.  He is believed to have provided the first exposure to allergy testing and desensitization to medical students.

In over 175 writings on allergies, he listed a variety of proteins that might cause asthma (6):

• Ragweed
• Horse hair
• The spit protein of wheat
• Egg white
• Goose feathers
• One meat, as beef
• One fish, as codfish
• Dust  (4, page 21)
• Fumes
• Animal dander
• Molds (5)

Other than removal from or fixing the causative agent, Rackemann recommended the following as treatments for asthma (note that the treatment for asthma improved throughout Rackemann's career) (4):

• 0.25 ml Adrenaline chloride repeated every half hour as needed (almost always works for all cases of asthma)
• Smoking strammonium leaves
• Cocaine nasal spray
• Morphine (rarely works)
• 20-25 mg of ephedrine three times a day as an alternative to adrenaline
• Potassium iodide
• Ipacec
• Moving to a dry climate
• No eating during an attack
• Aminophylline in cases where adrenaline doesn't work (after it was proven to be an effective bronchodilator in 1922, it became more prominent intravenously after studies proved it to be effective in 1937.  I have an upcoming post about theophylline)
• Diuretics for pulmonary edema (although we now know pulmonary edema is associated with cardiac asthma and not true asthma)

Burrage explained that Rackemann provided some of the first exposure to allergy skin testing that students had ever had. Other than Dr. Robert Cooke, Rackeman made more contributions to the understanding of allergy than any other physician. His name was well known within the medical communities in the United States as well as several other countries. (7)

He was a community organizer.  In 1923 he became founder of American Society for the Asthma and Allied Conditions and founder of the Allergy clinic at Massachusettes General Hospital, the first of its kind in the U.S.  He was the first president of the American Association of Allergy in 1934.  Ultimately these two organization merged to become The American Academy of Allergy.

Based on respect for Rackemann and his belief that asthma was an allergic condition and a nervous condition, most emphasis on asthma research was focused on these areas.  While he was on the right track and had noble intentions, this may have slowed the progress of asthma wisdom in other areas.

Yet, it was, Dr. Rackemann's interest asthma drove others to study it more intensely in the years between WWI and WWII. This resulted in a continued growth in asthma and allergy wisdom. Asthmatics should remember him as the most well known and respected asthma expert of the first half of the 20th century. He passed away in 1973 at the age of 85.

His dictum was "there is always something that can be done to help the asthmatic." (7) It was this way of thinking that lead to his many observations about allergy and asthma that lead to improved care for the asthmatic patient.

References:

1. McFadden, E. R. Jr. "A Century of Asthma," American Journal of Respiratory and Critical Medicine, Vol 170, pages 215-221.  
2. Adkinson, N. Franklin JR, "Is Asthma Always An Allergic Disease?", 1946, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2376710/pdf/tacca00085-0288.pdf
3. Rackermann, Frances M., "A Clinical Study of One Hundred and Fifty Cases of Bronchial Asthma," Archives of Internal Medicine (The American Medical Association), Oct., 1918, Vol. 22, No. 4, page 517-552
4. Brenner, Barry E., ed., "Emergency Asthma," 1999, New York
5. Rackerman, Francess M., "Molds as a cause of hay fever and asthma," 1937, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2242158/pdf/tacca00017-0255.pdf
6. Rackerman, Frances M., "Asthma, Hay Fever and Allied Conditions," The Medical Clinics of North America, Jan. 1920, Philadelphia and London, pages 1065-
7. Burrage, Walter S, "Francis Minot Rackermann, M.D.," Trans. Am. clin. Climatol. Assoc., 1974, 85;xliv
8. Rackemann, Frances M., "Nervous Factors in Asthma," 1969

1810: Robert Bree's 4 Species of Asthma

Robert Bree, our formost expert on asthma during the first half of the 19th century, described four species of asthma in his 1797 book, "A practical inquiry into disordered respiration: distinguishing the species of convulsive asthma, their causes and indications of cure."   

His "species" of asthma are based on his theory that asthma, and dyspnea, are caused by some irritating or peccant matter, and the asthma will continue until this peccant matter is removed.  The asthma attack, hence, is the effort of the body, or lungs, to expectorate this matter.  In this way, an asthma attack usually ends with the expectoration of sputum.

Now that we understand that, here are his species of convulsive asthma:

1.  The first species:  It's called Periodic or sometimes Convulsive Asthma (as described by John Cullen).  It's usually preceded by dyspepsia (irritated stomach).  It may show symptoms for years before it turns into a fit of asthma.  Dyspepsia is aggravated during the attack of asthma.  This usually effects the melancholic personality.  This is irritation of the serum within the lungs.  (1)

Symptoms include ("When an asthmatic feels these symptoms, he may be convinced that his enemy is at hand.":

• Flatulence
• Distended bowel
• Pain over forehead and eyes, which may become worse in the evenings
• Eructation of wind (burping)
• The evenings are attended with sleepiness
• Irritability that repels friends
• Tingling and heat in the ears, neck and breast (itching of the lungs)
• A motion to expel contents of the bowels
• Uneasiness of abdominal muscles
• After sleeping, he wakes with great difficulty of breathing
• Feels need to have an erect posture
• Inspiration performed with great effort of the muscles, but never performed deeply
• Diaphragm seems to descend with great difficulty against a force
• Speaking becomes distressing
• Irritibility of mind continues
• Wheezing sound on respiration
• There is a propensity to make water (pee, urinate), which is copious (lots) and pale
• After several hours cough birngs up phlegm
• Relief follows
• Tranquil state of feeling induces sleep with wheezes
• Remission on second day
• Expectoration of phlegm on 2nd or 3rd day ends the episode

2.  The second species:  Like the first it's caused by an irritating matter in the lungs.  It's accompanied by little or not expectoration of mucus.  For this reason it's commonly called Dry asthma. This is irritation from areal acrimony within the lungs.  (2)

Symptoms include:

• Little sputum, or none
• It comes on suddenly
• Succeeds sudden changes such as alterations in the wind, or a change of situation.
• The cause is of acrid or offensive quality, such as a strong smell, or subtle matter carried by the air. 
• The irritant is inhaled and attaches to the bronchial pipes or tracheal membrane. 
• The irritant usually atatcks by day more so than night
• No wheezes
• Action of intercostals and abdominal muscles are increased (as in other species of asthma)
• Dry cough
• Inflammation
• Hoarseness
• More prevalent in populous places or manufacturing places
• May come on suddenly when you come upon a town, and go away when you get back to the pure air of the country

3.  The third species: This is when the irritating matter that causes convulsive asthma is found in some organ other than the lungs. These causative organs are generally found below the thoracic cavity, such as the stomach or other viscera.    However, it cannot be proven the irritating matter was not present in the lungs at the same time. The irritating matter of another organ might be removed by an unobserved power of absorption, and the irritating matter of the lungs may be removed through expiration.

Many physicians doubt another organ causes asthma, and therefore inappropriately give blame to the lungs.  Many people think the lungs are the cause because of the respiratory distress.  For example, some physicians have found a link between spasm of the bladder or rectum and spasms of diaphragm and abdominal muscles, which are muscles "subservient to respiration."  In this way, Bree believed abdominal problems can cause respiratory problems.  (3)

4.  The fourth species:  This is convulsive asthma that is dependent on the habit of the person, and caused by sensation, after the irritation has been removed from the thoracic or abdominal viscera. I believe the idea here is that the asthma is caused due to the treatment of some other disease. Paroxysms return by minute causes in effect, such as mental association with the idea of being short of breath.  This usually is seen in those with frequent episodes of species 1-3.  For this type opium or other antispasmotics seem to work quite well. (4)

Further reading:

• To see other remedies for the above species see this link.
• To learn more about Dr. Robert Bree's definition of asthma click here
• To view the history of asthma click here

References:

1. Bree, Robert, "A practical inquiry into disordered respiration: distinguishing the species of convulsive asthma, their causes and indications of cure," 4th ed., 1810, London, page 43- 56
2. Bree, ibid, pages 182-193, 286-287
3. Bree, ibid, page 194-212, 287-290
4. Bree, ibid, pages 213-233, 290-292

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