1800-1900: Eleven asthma theories

The 19th century was an "age of enlightenment" where physicians and scientists started to question old theories of medicine and come up with new ones.  This is an important time in our history, because without it we might probably still be stuck with primitive medicine.When it came to asthma, this era was very significant.

Think of it this way:

• Before 400 B.C. asthma was just another mysterious disease caused by evil spirits or gods.
• In 400 B.C. the Hippocratic writers defined asthma as dyspnea. 
• Around 1700 John Fuller defined asthma as a disease entity of its own, slightly more severe than dyspnea and less severe than orthopnea 
• During the 18th century asthma was basically believed to be a disease in some way associated with and caused by sputum.

By the year 1900, or shortly thereafter, the following were the theories supported by one physician or another.  While the first two on this list were headed out the door, surely some physicians still held on to them for dear life.  The remainder are theories debated for the eternity of the century

The 19th century theories of asthma were:

1. Humoral theory of asthma:  That asthma was caused by an imbalance of the four humours: black bile, yellow bile, phlegm and blood.  This was the prevailing theory from about 400 B.C. (and probably sooner) when Hippocrates defined it, and the 1st century when Galen reaffirmed it, to the 19th century when scientific theories disproved it. 
2. Dyspnea theoery of asthma:  That asthma and dyspnea are the same thing was established by Hipporates.  Basicalllly anything that causes you to be short of breath is asthma; asthma is a symptom, an entity, as opposed to a specific disease. This theory was on the way out the door by the turn of the 19th century, although was pretty much the prevailing thought until the 18th century when scientists and physicians realized there were various causes of dyspnea, and started treating asthma as a disease and not just a symptom.  
3. Bronchitic theory of asthma:   Wheezing and dyspnea depend on obstruction of the air tubes by the inflammatory products of bronchitis. This results in excessive mucus production. (this is essentially chronic bronchitis). Dyspnea is less severe and more constant. This was the prevailing theory during the 18th century, and it made its way into the 19th century through the writings of Dr. Robert Bree.  A variation of this theory held great sway at the end of the 19th century and was referred to as the Theory of vessel turgescence.  This is basically inflammation of the mucosal membranes that line the respiratory tract.  
4. Spasmotic/ convulsive theory of asthma:  Contraction or spasms of the muscles that line the bronchioles are a main component of asthma.  Celsus (25 B.C.-50A.D.) defined asthma is caused by "the narrow passage by which the breath escapes, it comes out with a whistle."  The theory was introduced to the medial community by Thomas Willis in 1682, and William Cullen in the next entury fine tuned it, which is why it was so hot during the 19th century.
5. Nervous theory of asthma:  The belief that asthma is nervous in origin, or caused by things that influence the mind, such as strong emotions (laughter, crying), stress, excessive happiness, excessive sadness, a yearning for the mother, etc. This idea came about early in our history because there were no observable organic lesions or scarring in the lungs of people who suffered from it during life. Therefore, people with asthma were often burdens on society as they couldn't do things normal people do.  The idea was introduced to the medical community in the 16th century by Jean Baptiste van Helmont and Thomas Willis, and in the 18th century by William Cullen.  It was proven by the experiments of Francis Ramadge in 1835, Joseph Bergson and Amedee Lefevre win 1836, and Francis Romberg in 1841.  It was given true credibility by the writings of Henry Hyde Salter during the 1850s.  The main idea of this theory was that asthma was characterized by periodic attacks, followed by periods where the breathing was normal. 
6. Paralytic theory of asthma:  Asthma is caused by paralysis of the respiratory muscles and this results in dyspnea (this is essentially emphysema).  This idea was first established by Dr. Rene Laennec around around 1810 or 1820.  "Bronchial muscles are paralyzed and dyspnea is expiratory, more more constant, and less spasmotic. (1, page 37)
7. Diaphragmatic spasm theory of asthma:  That tonic spasms of the diaphragm caused asthma.  This theory may have been devised by examining the way asthmatic people breath. This theory may have first been proposed by Thomas Willis (1621-1675) and Neumaun (?).  It was also later supported by (M. Alton) Wintrich in the mid 19th century, and later confirmed by Heinrich von Bamberger (1822-1888) in around 1870.
8. Cardiac theory of asthma:  This is the theory that asthma is caused by blood being sucked into the lungs causing congestion and dyspnea. During the 19th and early 20th centuries, it's often referred to as a type of asthma.
9. Reflex theory of asthma:  Something other than the lungs causes it.  Eating too much or eating certain foods can effect a nerve and send a "reflex" signal to the lungs to respond. Catarrh or inflammation of the nose can cause spasm of the muscles of the lungs by reflex action.  Most who support this theory believe some form of disturbance in the blood is the result.  Other causes of this can be a response from the urea, disturbance of metabolism, etc. However, some who support this theory not it's just an extension of the nervous theory of asthma.
10. Hay fever theory of asthma:  Hay fever leads to asthma.  Some speculate inflammation (or catarrh) of the upper airway leads to inflammation of the lower airways of the lungs, leading to bronchitis or asthma.
11. Other:  Yes, lots of other.  Some doctors just let their imaginations fly free. Dr. Breuer, for example, "believed there was an automatic control of breathing through the vagi and that the stretching of the alveolar walls stimulates expiration and hinders inspiration. An increasing of the total lung volume, he thinks, would tend to stimulate expiration rather than inspiration." (1, page 37) Some theories may have been scientifically justified, and others, such as Breuer's, mere speculation. Other physicians noticed asthma improved after removal of polyps in the respiratory tract and sinuses.

There are also many physicians who believe asthma is not a disease at all, rather a symptoms of  some other disease process, either known (such as heart, lung or kidney disease) or unknown (mysterious).  Yet these physicians continued to stay in the minority.

Other than the bronchitic theory of asthma, most of these theories were generated either at the tail end of the 18th century or the earlier part of the 19th.  Generally, various physicians chose one or two of these theories as their favorite, and found evidence in support of that theory, adjusting the definition slightly as evidence indicated.

In 1917 Orville Harry Brown gave us a good synopsis of the above theories:  "The multitude of theories some ingenious and helpful and others far fetched and convincing evidence of a fruitless search, have failed to receive much attention."  (1, page 25)

In other words, while these seven theories were the main theories debated during this era, there were many more where that came from.  Regardless that most of the above theories started as speculation, they held significant sway at one time or another among the medical community.  

So this is the theme that leads us into the 19th century. So which of these asthma theories won the era?

References:

1. Brown, Orville Harry, "Asthma, presenting an exposition of nonpassive expiration theory," 1917, St. Louis, C.V. Mosby Company.  The above mentioned theory of vessel turgescence comes from this reference also on page 25. 

600-476 B.C Unhappy dead Roman men caused diseases

In the ancient world, which to many historians ended with the fall of Rome in 476 A.D., disease was believed to be caused by spirits.  In Ancient Rome, however, it was, more specifically, caused by the souls of unhappy deceased men.

Historian Harold Johnston explains that the Romans were very much so attached to their families.  Family, however, was not defined as a mother and father and children, as it is today.  In Roman times, a family consisted of one man who was in charge of the entire household, and he was called the pater familias, or Head of Household.  (1, page 21)

Johnston explains that the pater familias was the legal owner of all the profits made by the rest of the family, and the legal owner of all material possessions, which included all the slaves.  Under his possession was his wife, his children, his children's children, and all the female spouses of his male children.  His female children would be given up in marriage, and given to the pater familias of the house she is marrying into.  (1, page 21)

The descent of the family was traced through males, and all males who could trace their ancestry to a common male were thus called agnati, "and this agnatio was the closest tie in relationship known to the Romans."  (1, page 25)  

The significance of the agnatio is in the Roman belief as to what will happen to every Roman male in the afterlife.  Johnston explains this significance as follows: (1, page 28-29)

The importance they attached to the agnatic family is largely explained by their ideas of the future life. They believed that the souls of men had an existence apart from the body, but not in a separate spirit-land. They conceived of the soul as hovering around the place of burial and requiring for its peace and happiness that offerings of food and drink should be made to it regularly. Should these offerings be discontinued, the soul would cease to be happy itself, and might become perhaps a spirit of evil. The maintenance of these rites and ceremonies devolved naturally upon the descendants from generation to generation, whom the spirits in turn would guide and guard.

So you can see that if a Roman did not perform family life in accordance with tradition, he would therefore be offending the spirit, and this would result in sickness.  If appropriate ceremonies and sacrifices are not made, sickness may result.  And, as we all know, both allergies and asthma are a sickness that might consume a man.

Johnston continues: (1, page 29)

The Roman was bound, therefore, to perform these acts of affection and piety so long as he lived himself, and bound no less to provide for their performance after his death by perpetuating his race and the family cult. A curse was believed to rest upon the childless man. Marriage was, therefore, a solemn religious duty, entered into only with the approval of the gods ascertained by the auspices. In taking a wife to himself the Roman made her a partaker of his family mysteries, a service that brooked no divided allegiance. He therefore separated her entirely from her father's family, and was ready in turn to surrender his daughter without reserve to the husband with whom she was to minister at another altar. The pater familias was the priest of the household, and those subject to his potestas assisted in the prayers and offerings, the sacra familiaria.

Basically this means that the Head of the Household was in charge of making sure tradition was followed in order to keep the male ancestors happy as they hover over their graves.  An unhappy male soul results in an unhappy household, one full of grief and sickness.

One problem that Roman males had is if they had no children, or if their male child passed away.  When this happened, "he had to face the prospect of the extinction of his family, and his own descent to the grave with no posterity to make him blessed."  (1, page 30)

To accommodate for this, he had two options open to him: (1, page 30)

1. He might give himself in adoption and pass into another family in which the perpetuation of the family cult seemed certain, or
2. He might adopt a sen and thus perpetuate his own

Of course, as Johnston notes, " He usually followed the latter course, because it secured peace for the souls of his ancestors no less than for his own." 

Anyway, I find this very interesting.  What do you think?

References:

1. Johnston, Harold Whetstone, "The Private Life of Romans," 1908, Chicago, Atlanta, New York, Scott, Foresman and company

1840: Is asthma a disease of bronchospasm?

The year 1840 represented a turning point in the evolution of defining the disease called asthma. That was a year in which William Budd flat out rejected the spasmotic theory of asthma, and a year in which Charles H.B. Williams performed tests that confirmed without a reasonable doubt the same spasmotic theory Budd rejected.

Dr. William Budd:  J.B. Berkart, in his 1878 book "On Asthma" wrote extensively about Budd, and how he aimed to disprove the convulsive theory of asthma.  Berkart explains that Budd repeated experiments previous authors wrote would produce bronchospasm and he didn't produce the same results. In fact, as Berkart explains, Budd flat out "rejected the theory of a bronchial spasm, and even doubted whether the circular fibres were muscular, as alleged." (1, page 25)

Budd, thus, did not believe the fibres discovered to be wrapped around the air passages of the lungs were muscular, let alone that they spasmed and caused narrowing of the air passages that resulted in asthma.

So now we had proof the bronchospasm theory of asthma was fallacious. Or did we? Budd was proven wrong that same year by Dr. Charles J. B. Williams.

Dr. Charles J.B. Williams: He is the same brilliant physician who came up with the term lub dub to describe the sounds emitted by the beating of the two chambers of the heart.  He also studied asthma, and for that we are fortunate, as he's the person who ultimately proved the spasmotic theory

Berkart explains that Williams performed experiments that proved without a doubt "that mechanical and electrical stimuli do produce contraction of the air-tubes. Thus the theory of a bronchial spasm obtained the support of experimental physiology. And even those who until then wavered in their opinions as to the possibility of such a spasm saw now no reason for doubting, but readily accepted that doctrine."  (1, page 26)

John Charles Thorowgood, in his 1878 book "Notes on Asthma," explains:

"The larger bronchial tubes have their cartilaginous rings as elastic spring-openers; the smaller tubes, lying nearest to the vesicular parts of the lung, have no cartilaginous rings, but are entirely muscular; and (Rene) Laennec and (Daniel) Reisseissen, and more recently Gratiolet, have detected muscular fibres in air-tubes less than one line in transverse diameter. The contractility of these fibres under the influence of electrical, chemical, and mechanical stimuli was proved in a series of ingenious and conclusive experiments by Dr. Williams many years ago."

Williams became the first to break asthma into two types: spasmodic and paralytic. Berkart wrote that as of the writing of his (Berhart's) book in 1878, the two terms described by Williams were the ones accepted by most experts.  However, other doctors would continue to reclassify asthma to their own content and amusement.

The ideas of these two men would be debated the rest of the century, although, in the end, Williams came out the winner.

References:

1. Berkart, J.B., "On Asthma: It's pathology and treatment," 1878, London,  Chapter II, "History of Asthma," page 12
2. Thorowgood, John Charles, "Notes on Asthma," 1878, 3rd edition, London, J and A Churchill

1920-1980: The evolution of oxygen delivery devices x

By the mid 1920s many of the challenges of oxygen therapy had been tackled.  Oxygen could be easily produced, stored in tanks, and delivered to the patient.  There also existed the means of confirming oxygenation status of patients, and the effects of oxygen therapy.  So the stage was set for oxygen to be introduced to hospitals.

In 1922 John Haldane wrote about his research in "The Therapeutic Administration of Oxygen."
Soon thereafter oxygen tanks became more and more common at the patient bedside.  The tanks were stored in closets, and when needed were strapped by the patient bedside. 

There were various devices available for providing oxygen, which included a metal nasal cannula, a nasal catheter, the oxygen chamber, the Haldane Apparatus, and the oxygen rebreather mask or mouthpiece and an oxygen tent.  .  For patients that were comatose, any device needed to provide therapeutic oxygenation could be used.  For awake and alert patients, the mask posed a claustrophobic feeling, and it was also hot.  The same was true with the oxygen tent.  So the physician would basically have to base what oxygen device he used on the patient.

According to one of my readers over at Respiratorycave.blogspot.com "The first practical oxygen tent was invented by Doctor Benjamin Eliasoph in 1921, at The Mount Sinai Hospital,New York, with rubberized fabric from the Goodyear Rubber Company, Aeronautical Division used for balloons such as the widely known Goodyear Blimp.  This information is confirmed in a New York Times obituary for Dr. Benjamin Eliasoph, which notes: "Dr. Benjamin Eliasoph, a physician at Mount Sinai Hospital who was a pioneer in the design of the oxygen tent, died Sunday at the hospital. He was 70 years old."

The first mass producible oxygen tent was invented by Doctor Leonard Hill.  It consisted of a canopy with slots so the patient could see out that was placed over the bed and patient, and a machine was set at the bedside that blew oxygen into the tent and over the patient.  Glover explains that there was no means of cooling the atmosphere inside these tents, and being inside was almost unbearably hot and uncomfortable for many patients.

Dennis Glover, in his 2010 book "History of Respiratory Therapy: Discovery and Evolution," said that the most common use for the oxygen tent was for patients presenting with cyanosis due to heart failure or pneumonia.  Some patients would beg to get out of the tents, Glover explains, yet once out they would became short of breath and they'd beg to get back in.  So it was sort of a double edged sword for the patient until the patient got better, if they got better.  Some critics complained such tents basically provided a tortuous method of ending a person's life, and petitioned for their demise.

Yet these tents were ultimately refined in 1926 by Alvin Barach so that the air would blow over ice, and this would cool the air inside the tent.  They were refined again in 1931 by John Emerson. 

In 1926 Alvin Barach invented an oxygen tent that blew air over ice chips to cool the temperature inside the tent.  This made it so being inside the tents were much more bareable.   Usually these tents were reserved to patients with pneumonia and heart failure. (2) In 1931 John Emerson invented an oxygen tent that had a cooling system.  Previous devices were prone to rust and failure.  (7)

The metal cannula was another device that was used.  It was a narrow metal pipe that was secured to the forehead by a strap that wrapped around the head, and at the lower end of the pipe were two prongs that were inserted into the nares.  I can imagine this may have felt awkward for the patient, but it may have been much nicer than having to lie inside an oxygen tent or having a rubber mask on your face.

The nasal catheter was introduced to the world by Lane in 1907, and introduced to the United States in 1931 by Waters and Wineland. (3)  Between 1920 and 1960 it was the most widely used method of delivering oxygen to patients was the nasal catheter. (8)

Glover explains that by the 1960s vinyl was invented and this technology spread to the medical profession.  Masks, catheters, nasal cannulas and tubing was now made of this new material, and were much more comfortable for patients.  (2)  Another benefit was the material was see through, and this allowed the caregivers to see right away if the mask was filling with secretions, vomit or pulmonary edema. 

Vinyl nasal cannulas also became the preferred basic oxygenation device, and this slowly caused the demise of the nasal catheter, which is no longer manufactured.

The nonrebreather was also introduced during the 1920s.  The only basic difference from the rebreather was a one way valve which opened on exhalation and allowed the patient to exhale into the room.  The one way valve closed on inspiratoin and caused the patietn to breathe approximately 80 percent oxygen that was stored in the reservoir. 

This was a good device for oxygenating patients suffering from acute anoxia, although oxygen tanks weren't trustworthy, rubber masks stuck to faces, and physicians, nurses, nurses aides and orderlies got busy.  So if the tank all of a sudden was empty, the patient might suffocate.  So to extinguish this risk, one of the valves was removed and the masks ultimately became more of a partial rebreather, providing around 50-60 percent oxygen. 

By the 1950s physicians observed that some patients with chronic bronchitis and emphysema became lethargic when exposed to high levels of oxygen.  So this brought about the introduction of the venturi mask.  This new mask was based on the venturi principle, and the degree of the opening on the venturi determines the amount of air entrained.  This allowed the physicians to provide an accurate and specified amount of oxygen to the patient.

So for patients you don't want to give too much oxygen to, the venturi mask was recommended.  Generally, for patients with bronchitis and emphysema, you would either use a low flow device like a nasal catheter or cannula, or you'd use the venturi mask.  These masks were (are) also nice for when you have a patient with an irregular respiratory rate because regardles of the patients minute ventilation, the patietn will still receive the preset level of oxygen. 

By the 1980s plastic had been invented, and during this decade most respiratory therapy devices were slowly replaced by plastic.  Plastic nasal cannulas, masks, and nebulizers were introduced in the early 1980s and slowly phased into various hospitals through assimilation. 

The earliest oxygen humidifiers were either made of metal or glass.  Until plastic was invented, none of the equipment here was disposable, and needed to be washed, sterilized, dried, and restocked on the shelves before being set up on the patient. 

References:

1. Hess, Dean,  Neil MacIntyre, Shelley Misha,"Respiratory Care:  Principles and Practice," page 281
2. Glover, Dennis, "History of Respiratory therapy: discovery and evolution, ," 2010, Indiana, page 94
3. Wyka, Kenneth A., Paul J. Mathews, John Rutkowski, editors, "Foundations of Respiratory Care," 2012, U.S., Delmar, page 9
4. Hess, Dean,  Neil MacIntyre, Shelley Misha,"Respiratory Care:  Principles and Practice," page 281
5. Barach, Alvin L., "The Therapeutic Use of Oxygen," The Journal of the American Medical Association, Vol 79, No. 9, Chicago, October 26, 1922, page 693-699
6. Barach, Alvin L, Margaret Woodwell, "Studies in oxygen therapy with determinations of blood gases," Archives of Internal Medicine, Vol. 28, 1921, Chicago, American Medical Association, pages 367-393
7. Branson, Richard D, "Jack Emerson:  Notes on his life and contributions to Respiratory Care," Respiratory Care, July 1998, vol. 43, no. 7, pages 567-71

Further Reading:

1. Use of oxygen in pneumonia in an oxygen chamber, page 466

1910-1920: The oxygen revolution

Joseph Barcroft (1872-1947)
In 1886 he received his M.D. from Cambridge,
and began his study of hemoglobin.
He exposed himself to different environments
to determine their effects on the human body.
.

Three significant events occured at the dawn of the 20th century that resulted in increased interest in supplemental oxygen therapy. The first was the invention of a means of measuring oxygen saturation. The second was an experiment that Dr. Joseph Barcroft performed on himself. The third was experiments by WWI physicians to find a treatment for pulmonary edema caused by gas poisoning.

The ability to draw arterial blood was a significant discovery. It was hurter in 1912 who introduced the method. (2, page 693)

Yet even more significant was the machine the blood could be inserted into that would determine the oxygen saturation of the blood. This test basically determines what percent of hemoglobin molecules in the blood of a patient is carrying an oxygen molecule

John Scott Haldane (1850-1936)
He graduated from Edinburgh University in 1884,
and worked with his uncle at Oxford,
where he became interested in air,
its composition, and effects on humans.

Adolf Fick of Germany and Paul Bert of France described oxygen tensions as units of partial pressure, and it was these units that made it possible to describe the difference between arterial and venous blood. Since the partial pressure of oxygen in (1, page 94) (2) (6)

Donald Dexter Van Slyke (1883-1971) and John Scott Haldane (1892-1964) of Scotland developed effective means of measuring these differences. (1, page 94) (2) (6)

Further studies by various experts determined the normal levels and critical levels of oxygenation. It was determined that a normal arterial saturation of hemoglobin is between 95 and 98 percent, and a normal venous saturation is between 70 and 75 percent. These new values allowed physicians to monitor a patients oxygenation status, and the effectiveness of oxygenation therapy. (2)(3, page 369)

Among the first to prove the significance of this discovery was Sir Joseph Barcroft, who lived for six days in an atmosphere that had 18 percent oxygen in the air, as opposed to the normal 21 percent that's in roomair. Alvin L. Barach, a pioneer in oxygen therapy, liked to use Barcroft's experiment as an example to prove the significance of oxygenation.

Barach explained:

"On the last day, the oxygen saturation of his arterial blood was 88 per cent., and after the performance of work 83.8 per cent. He lay in the chamber racked with headache, with occasional vomiting, and at times able to see clearly only as an effort of concentration. He became faint on exertion. His pulse, normally 56, had risen to 86. These effects were apparently due purely to oxygen want. The degree of anoxemia that produced them has frequently been found in pneumonia and heart disease by the investigators mentioned above. In many instances, the saturation of the arterial blood falls to far lower levels. It would, therefore, seem likely that lack of oxygen in the degree often found in disease would produce bodily discomfort, disturbances in function and damage to living structure." (3, page 369)

The effects on Barcroft were similar to the effects of pneumonia and heart failure for some patients. Studies showed that the oxygen saturation could range from 75-95 percent in cases of cardiac insufficiency, and 60-95 percent in cases of pneumonia. (2, page 693)

So it became apparent these diseases, as they progress, decrease the amount of oxygen that gets to the blood and to hemoglobin.  

Various studies, including the Barcroft study, proved that a low level of oxygen stimulates the central nervous system to stimulate various changes within the body in an attempt to return oxygenation back to normal: heart rate increases, respiratory rate increases in rate but decreases in depth, patient may become delirious and may have hallucinations  If not treated, death may result.  (2, page 694)

So these studies proved to the medical community the significance of observing the signs and symptoms of poor oxygenation and speedily treating them with oxygen. (2, page 694)

Oxygen was not meant to cure, but to treat the symptom of low oxygenation long enough to allow the physician to remedy the underlying condition, which may include: (2, page 694)

• Pneumonia
• Acute Cardiac Failure
• Severe Hemorrhage
• Epidemic Encephalitis
• Ascent to high altitudes
• Complications of chronic cardiac insufficiency
• Pulmonary Edema
• Acute Bronchitis
• Carbon Monoxide Poisoning
• Nitrous Oxide Poisoning
• Other anesthesia

Further studies also allowed physicians the opportunity to determine that a therapeutic percent of oxygen for most diseases is between 40 and 60 percent, and it's for this reason the oxygen chamber, oxygen catheter, and nasal cannula generally are not effective for oxygenating patients with severe oxygen deprivation. (2, page 696)

Studies likewise showed greater than 70 percent could cause pneumonia, and did so in rabbits. (3, page 373)

It was probably based on these and similar studies that John Haldane, one of the pioneers of oxygen therapy, would recommend 41% oxygen administration continuously for patients suffering from anoxemia, a deficiency of oxygen in the blood (Haldane would coin a new term to describe this: hypoxemia). (6) (7) (8)

In fact, it is said Haldane once mused:

Intermittent oxygen therapy is like bringing a drowning man to the surface of the water—occasionally. (7) (8)

Yet even while he and other physicians proved the usefulness of continuous oxygen therapy during WWI, it would take a few more years for it to catch on. (6)

Oxygen mask designed by Haldane in 1917

A third significant event was the gas poisonings that occurred during WWI. Phosgene was used by the enemy on the war front because, when it combines with water in the lungs, it creates hydrochloric acid, which damages lung tissue. If inhaled in high enough doses it may cause pulmonary edema within 6-10 hours, leading to acute respiratory distress syndrome (ARDS).  As the illness progressed, the lungs lose their ability to pass oxygen to pulmonary capillaries, therefore causing anoxemia or hypoxemia, a deficiency of oxygen in the blood. (6)

While oxygen was not thought to cure these patients, it was believed that it would treat the symptoms caused by anoxemia, particularly cyanosis and dyspnea.

Sometimes patients who presented with pulmonary edema due to gas poisoning were treated in oxygen chambers, which could be supplied with 40-60 percent oxygen. These chambers were found to be effective in treating cases of chronic gas poisoning. Some patients would spend up to 16 hours a day inside one with good results. (3, page 360)

However, this therapy wasn't practical for common use.

Another means of providing these patients oxygen was to use a tube or funnel to aim the oxygen at their faces, although studies showed this provided no more than a 2 percent increase in oxygenation of inspired air.

So this opened the door for an improved oxygenation apparatus that was easily portable by medics, comfortable to wear, could be used long term for chronic cases, and provided a therapeutic dose of oxygen.  John Haldane invented such a device, and it was called the "Haldane Apparatus." (3, page 370)

Alvin Barach said Haldane's apparatus provided oxygen blended into the air the patient inspired, and by doing this the amount of oxygen making it to the alveoli was greatly increased. By this means, the patient was supplied with a therapeutic level of oxygen. (3, page 370)

Barach described the device as consisting of an oxygen tank, a reducing valve, and a face mask. He said:  (3, page 370)

"The mask was connected with a connecting bag which received oxygen from the tank, and with the outside air, from which the patient breathed. Oxygen was added to the inspired air in amounts of from one to four liters per minute. This was largely used in acute cases with generally good results." (3, page 370)

The problem with the Haldane apparatus was the only patients who tolerated it were those who were comatose. It worked great for these patients. Yet for others, for those who were awake and alert, it was not comfortable. Patient's complained that having the mask over their faces created a feeling of claustrophobia, and the mask was also hot and stuffy. This was especially a problem on hot days. Some patients simply didn't tolerate the mask, and some even ripped it off, refusing to wear it. (3, page 370)

Another problem, a pretty severe one actually, was that when a patient presented with copious pulmonary edema that it poured forth from the mouth as pink frothy secretions, it sometimes occluded the airway.  Because the masks were made of solid black leather, busy clinicians sometimes didn't recognize this was occurring. Some patients died as a result of this occurrence.

So this opened the door for a more comfortable and safer oxygenation device.

One such device was the nasal cannula or prongs devised by Captain Adrian Stokes, M.D., in 1917.  Stokes created the device while triaging patients on the war front who were suffocating due to pulmonary edema, and to which the tight fitting rubber mask of Dr. Haldane was not feasible.  The metal cannula provided less oxygen that Haldan's device, although it helped medics keep pulmonary fluid from re-entering and blocking the airway.  (1, page 38) (3, page 370)  (5, page 8) (6)

Stoke's cannula was a device similar in design to what we use today, although it was supplied by rubber tubing and the prongs were made of metal, and therefore was not very comfortable. However, patients tolerated it much better than the rubber mask, and of course it was safer. (1, page 38) (3, page 370)  (5, page 8) (6)

A similar device was the rubber nasal catheter, which was initially invented by Arbuthnot Lane in 1907, although re-introduced by Stokes in 1917. The catheter was introduced into the United States in 1931 by Waters and Wineland.  (1, page 17) (5, pages 8-9) (7, page 20)

The soft, rubber catheter (later made of pliable plastic) was a 12 inch long tube that was blindly inserted into one of the nostrils and then secured to the forehead. The patient would then open his mouth, depress his tongue to the bottom of his mouth, and the physician or nurse would check to see that the catheter was in place at the back of the airway. (4)

The end that remained outside the patient had a fitting to which oxygen supply tubing was connected.  On the distal side of the catheter, the side inside the patient's ariway. were a series of small holes to allow oxygen to enter the patient's airway.  (4)

Catheters were designed for adults and pediatrics, the flow was set at 1- 5 lpm, and the the delivered oxygen was 22-35%.  The catheter would stay in the nose for a day or two.  If it was needed longer a new catheter had to be inserted. (4)

Most experts recommended changing the catheter every 24 hours to prevent tissue breakdown, and most hospital protocols eventually called for changing it every eight hours.

So you can see that while it was more convenient for the patient, there was some risk to the patient too.  It also provided some inconvenience for hose taking care of the patient who required it.

While nasal catheters were simple to insert and manage, and while they were generally well accepted by patients, they did not provide enough oxygen in patients presenting with acute pulmonary edema or worsening pneumonia to eliminate cyanosis.  (3, page 370)

The nasal catheter was the most commonly used device for supplying supplemental oxygen prior to the invention of the modern nasal catheter in the 1960s.

Figure 2 --Apparatus for giving oxygen.(3, page 374)

Another option was a device similar to the one in figure 2.  The apparatus works this way: 

"The patient breathes through the rubber mouthpiece M (or a mask could be used) through the can of soda-lime C into a rebreathing bag B. The carbon dioxide exhaled is removed by the soda-lime, and oxygen is admitted from the tank O at a sufficient rate to keep B inflated.In this way the patient rebreathes pure oxygenfrom the apparatus,but since his nose is left open he dilutes this with a certain proportion of atmospheric air. In practice this results in the inhalation of from 40 to 60 per cent, oxygen." (3, page 374)

Yet another option was the oxygen tent. These were clear canopies that were made to cover the entire bed. A machine at the bedside provided an environment inside the tent of about 30 percent oxygen. These were effective as far as oxygenating some patients, although the original oxygen tents were hot and stuffy, and this particularly posed a problem on hot days.

Patients would generally go inside one long enough to catch their breath, and then they'd return to breathing room air. (1, page 94)

Barach recommended to physicians that the best means of measuring oxygenation status was by monitoring the heart rate, respiratory rate, and especially the level of cyanosis (bluish skin color). (3, page 370)

Caregivers would ultimately learn to monitor these signs, along with level of consciousness, before, during and after therapy.  This, they found, was the best means of monitoring the effectiveness of oxygenation therapy, and whether or not it was still needed.  (2)

What equipment to use to supply oxygen depended on what equipment was available, the physician taking care of the patient, and the independent oxygenation requirements of patient.

How long oxygen therapy was used primarily depended on the patient and how quickly, or slowly, the underlying condition resolved. (2)

Still, by 1922, when Barach wrote many of his papers, he explained that...

"the use of oxygen in medical therapy occupies at present an uncertain role." 

Despite Barach's doubts, the 1920s was an oxygen revolution of sorts.

References:

1. Glover, Dennis, "History of Respiratory therapy," 2010, Indiana, page 94.
2. Barach, Alvin L., "The Therapeutic Use of Oxygen," The Journal of the American Medical Association, Vol 79, No. 9, Chicago, October 26, 1922, page 693-699
3. Barach, Alvin L, Margaret Woodwell, "Studies in oxygen therapy with determinations of blood gases," Archives of Internal Medicine, Vol. 28, 1921, Chicago, American Medical Association, pages 367-393
4. Hess, Dean,  Neil MacIntyre, Shelley Misha,"Respiratory Care:  Principles and Practice," page 281
5. Wyka, Kenneth A.,  Paul Joseph Mathews, William F. Clark, editors, "Fundamentals of Respiratory Care," 2002
6. Grainge, CP, "Breath of Life: the evolution of oxygen therapy," Journal of the Royal Society of Medicine, October, 2004, 97 (10), pages 489-493
7. Heffner, JE, "The story of oxygen," Respiratory Care, January, 2013, volume 58, number 1, pages 18-30
8. Sekhar, KC., "John Haldane: The Father of Oxygen Therapy," Indian Journal of Anesthesia, May-June, 2014, 58 (3), pages 350-352

1698: Floyer's asthma symptoms, triggers, treatment

John Floyer's A Treaties on Asthma provides a neat description of asthma, which probably comes from his own experiences with the the disease.   (4, page 374) He describes himself as having periodic asthma, which is probably more in line with our modern definition of the disease.

About a century after the first edition of his book was published a fellow asthmatic and asthma physician by the name of Robert Bree would quote Floyer's description of an asthma attack as such:

"I have found, that by late sitting up I have put by the fit for a night or two; and I have found it commonly necessary to rise out of bed, especially in the summer time, and to sleep in a chair the first night of the fit.  Two nights before the fit asthmatics want sleep frequently." (2)

Perhaps it's from his own experience that Floyer decided asthma into four parts, which are basically broken down as: (1)

Floyer's A Treaties on Asthma (1698)

1.  Symptoms:  A history of the fits or the asthmatic attack. It's generally based on his scientific description of bronchospasm: (1)

• The attack usually begins at one or two of the Clock in the Night
• The breath if very slow (early sign)
• Fullness of stomach (early sign)
• A slight headache (early sign)
• Sleepiness (early sign)
• Feeling rigid
• Feeling stiff
• Feeling inflated (head seems to be filled with Fumes or Serous Humour)
• Began to suck in breath
• Straitness of breath, seems to be for want of an easie Inspiration
• Urge to sit in an erect Posture, that the weight of the viscera may pull down the diaphragm
• Enlarging of the breast during inspiration
• Muscles of inspiration strive and labour more vehemtly
• Muscles of expiration cannot easily perform the Contraction of the Thorax, being hindered by the Stiffness or Inflation of the Membranes in the Thorax
• Expriation is easier than inspiration
• Expriation is very slow, and leisurely (and wheezing)
• The patient can not cough, sneeze, spit or speak freely
• The diaphragm cannot contract itself to move downward
• Bronchi and trachea has its membranes and nervous fibres contracted which results in wheezing (mainly expiratory)
• Muscular Fibres of the Bronchia and Vesiculae of the Lungs are contracted adn that produces the Wheezing noise, which is most observable on expiration
• Convulsive cough before fit (inconsiderable)
• Phlegm is spit up (inconsiderable) 

2. The nature of asthma as he saw it: Basically based on Galanic principles: (1)

• A flatulent slimy Caccochymia which is bred in the stomach, and creates inflation there, and gives an effervescence in the blood and an inflation in the membranes in the lungs
• At 2 a.m. the Chyle is more plentiful in the blood.. and the viscid Chyle and Lymph will not easily circulate through the lungs of the asthmatics
• The Asthma is a High, Slow, Rare and Laborious Respiration, which depends immediately on the inflation of the Membranes of the Lungs by Windy Spirits, rarefied or propelled through the Glands of the Brain, either by external Accidents or periodic Febrile Effervescence (bubbling) of the Blood. 

3.  Triggers: (Accidental causes) or lifestyle causes or factors that precipitate an asthma attack: (1)

• Great heats or cold
• violent motions of the body or mind
• Excess in eating and drinking
• Venereal Pleasures
• Heat of the bed
• Changes of the weather to rain
• Snow
• Change in weather from frost to thaw
• Alteration of clothes
• Changes of the air at spring and fall (change in barometric pressure)
• Moist air (dry air is good for the asthmatic)
• Heat and smoke of from fires
• Fumes
• Perfumes
• dust
• Strong liquors and food
• Exercise
• Anger (makes humours more viscid)
• Fear
• Shouting
• Excessive study (upset the spirits)
• Any strong smells (candles put out, Smoak of tobacco, winie fermenting, soap making, burnign metals, etc.)
• Sadness makes humours more viscid 

4.  Treatment: (The cure of the fit) and preventative measures.  These are probably things he tried out on himself: (1)

• Light diet (fasting on day of attack with a light diet thereafter)
• Gentle Exercise
• Bleeding (performed in small quantities, but only in extreme cases)
• Blisters (Applied to limbs and shoulders)
• Narcotics/ opiates (if induced by sleep 'when nerves are filled with windy spirits'/ induce sleep)
• Abstinance of anger or shouting
• Emetics (to induce vomiting/  if excessive may bring on asthma/ monthly vomiting recommended)
• Feather in throat (another option to promote expectoration of viscid sputum
• Oxymel of squills (to induce expectoration)
• Clysters (laxitives) or Purges (violent purging should be avoided, but regular purges are recommended)
• Late sitting up (staying up late)
• Avoid extreme climate changes
• Febrifuges and Sudorifics to help fevers that accompany the asthma
• Diuretics such as millipedes and woodlice
• Cold water bathing (4, page 110)
• Apple water (4, page 110)

Click here for more asthma history.

References:

1. Floyers, John, "A Treaties on Asthma," 1698, London
2. Bree, Robert, "A Practical Inquiry into Disordered Respiration Distinguishing the Species of Convulsive Asthma, their Causes and Indication for a Cure," 1810, London, pages 123-124
3. Floyer, John, "History of cold water bathing," 1722, 5th edition, London, Printod form William and John, Innys, at West-end of St. Paul's Church-yard
4. Gill, M. H., "Review and Bibliographic Notices: "On the spasmotic asthma of adults," by Bergson, published Gill's book, "The Dublin Quarterly Journal of Medical Science," volume X, August and November, 1850, Dublin, Hodges and Smith, pages 373-388

625-690: Paulus Aegineta describes asthma

2

Paul of Aegineta was a Greek physician who gives us a very early
description of asthma.  He also provided for us one of the first
histories of medicine, thus preserving the thoughts on asthma
of some of the ancient physicians

So how did the ancients define asthma? To get an answer to this question we need look no further than the 7th century A.D. where Paulus Aegineta gives a summary of how physicians during his day viewed asthma (1).

He was born in Aegina in 625, was educated at the University of Alexandria, and grew to become a famous Greek physician.  His name was Paul of Aegina, although he is most known by history as Paulus Aegineta. (2)

He became a very skilled surgeon who provided many achievements in the surgical process.  He was among the first to describe a process called bronchotomy, which was an old term for tracheotomy.  Some consider him the originator of plastic surgery.  (3)
He was among the first to describe a process called bronchotomy, which was an old term for tracheotomy. 

He was also a well known expert on diseases of the heart. (4)

He was also a skilled writer, compiling a condensed account of medicine, from surgery to treatment of diseases such as asthma.  His seven books were interpreted into English in 1744 by Francis Adams titled, "The Seven Books of Paulus Aegineta."  The books not only influenced physicians during Aegineta's era, but subsequent eras including Avecena, Rhazes, Haly Abbas, Albucasis, and Fabricius ab Aquapendente.  (5)

While he is most famous for his surgical wisdom, he does provide accounts of various disease processes, such as asthma, and remedies to treat them.  Most of his ideas were borrowed from ancient writers, which makes him an important figure when trying to compile a history of any disease.

The following is how he, and perhaps the ancients in general, defined asthma.  This comes from his book "The Seven Books of Paulus Aegineta" translated by Francis Adams.  (6)

1.  Definition:  "Those who break thick without fever, like those who have run fast, are said to be asthmatic, that is to say, to pant for breath; and from their being obliged, they are called orthopnic. (6)

2.  Causes:  The affection arises from thick and viscid humours becoming infarcted in the bronchial cells of the lungs. (6)

3.  Symptoms:  Dyspnea is a common symptom which accompanies these and many other complaints. (6)

4.  Treatment:  The indications of cure for asthma is to consume the viscid and thick humour by attenuant and detergent medicines.  Wherefore the vinegar of squills will answer well with them, and the oxymel prepared from it; the baked squill itself will answer well triturated with honey; the antidote called heira, continued purging with drastic medicines, and vomiting from radishes.  And, in like manner, the round birthwort may be drunk, the root of the great centaury, the fruit and root of the cow-parsnip,the fruit of calimint, hyssop, iris, and gith.  Put a sextarius of slaters, into the earthen vessel, roast upon the coals; when whitened, pulverize, and, mixing with boiled honey, give a mystrum thereof before and after food.  If there be any urgent necessity, before doing all these things, open a vein and evacuate proportionably to the patient's strength; and stimulate the belly by clysters.  Externally to the chest we may apply cataplasms from figs, the flour of iris, and of barley, containing rosen, wax, and honey; and iris and manna may be sprinkled upon them.  Some benefit may also be derived from raw barley-flour with rosin, wax, iris, and manna.  We may use the more heating ointments, which as those of iris, dill, and rue.  But the following application is particularly proper: Of pumice stone, p.j; of burnt lees of wine, p.iv; of arsenic, p.j; of the schenanth, p. ij; of alcyonium, p.j; of aphronitrom, p.ij; pound, sift, mix with the ointment, and with it rub the parts about the chest, and use emollient ointments for attracting the humours. (6)

So while he is mostly known as being a prolific surgeon, he also gave us some pretty interesting descriptions of diseases, including asthma.

References:

1. Aegineta, Paulus, "The Seven Books of Paulus Aegineta," translated by Francis Adams, volume I, 1744, The Snydenham Society, pages 289-290  (commentary by Adams can be found on pages 407-09)
2. Greeka.com, "Paulus Ageneta: The most important physician of Aegina Greece, Saronic," http://www.greeka.com/saronic/aegina/aegina-history/aegina-paul-of-aegina.htm, accessed June 26, 2012
3. Gurunluoglu R, Gurunluoglu A., "Paulus Aegineta, a seventh century encyclopedist and surgeon: his role in the history of plastic surgery," Dec., 2001, 108 (7), 2072-9, based on a review of mentioned article at Pubmed.gov, http://www.ncbi.nlm.nih.gov/pubmed/11743404, accessed June 26, 2012
4. Virginia.edu, "Paulus Aegineta (625-690)," University of Virginia, Vaulted Treasures, http://exhibits.hsl.virginia.edu/treasures/paulus-aegineta-625-690/
5. Gurunluoglu, op cit, 2072-9
6. Aegineta, Paulus, "The Seven Books of Paulus Aegineta," translated by Francis Adams, volume I, 1744, The Snydenham Society, commentary by Adams can be found on pages 407-09
7. Junior, Democratus,  "Anatomy of Melancholy," translated by Robert Burton, 1827, London, Longman, Rees, Orme, and co., page 90
8. Fourgeaud, V.J, "Medicine Among the Arabs," (Historical Sketches), Pacific medical and surgical journal, Vol. VII, ed. V.J. Fourgeaud and J.F. Morse, 1864, San Fransisco, Thompson & Company,  pages 193-203
9. Drake, Miriam, "Encycopedia of Library and Information Science," 2nd ed., 2003, New york, page 1840
10. "Rhazes and the first clinically exact description of hay fever (seasonal allergic rhinitis)," Iranian Journal of Medical Science, 2010, September, vol. 35, no. 3, 263