Friday, August 26, 2016

1837: The botanic asthma remedy of Carter and/or Mathes

It is the year 1837, Andrew Jackson is president, you live on the frontier, and you are suffering from a fit of asthma.  What do you do to treat your difficult breathing?

Well, for one thing, you could grin and bear it and wait for nature to bring your breath back.  But there are too many uncertainties with this route, such as: how long can you suffer like this? What if your breath doesn't come back, then what?

Another option would be to find a doctor at some nearby village, which was highly unlikely.  Besides, what if the long ride there made your asthma worse and there wasn't a doctor, then what?

There was another option, one you might have read about in a local paper, and that was to seek the help of a root and herb doctor, which was in its hey day during the Jackson Presidency.

You certainly heard about Samuel Thomson and his army of root and herb doctors plastered across the nation.  Would there be one of these in the nearest village? It wasn't worth the risk to find out.

A fourth option might be your best bet, and this was to have in your possession a book of root and herb remedies written by a root and herb doctor.  You just happened to have on your desk such a book by J.E. Carter, and A.H. Mathe called, "The botanic physician."

The book contained every thing you needed to know about root and herb medicine, botanic medicine, folk medicine, Indian medicine, herb Medicine, stick medicine, or whatever you wanted to call it.  You read about the book a while back in some random newspaper you read, and you purchased a copy at some random general store.

You read some nasty things about these sorts of doctors, that they were copycats, quacks, or otherwise pent on peddling their fake products, most of which contained just alcohol, just to make a buck.  But you weren't concerned about that, especially while you were sitting in your log cabin, miles from any village, struggling to breathe.

Your best hope was that Carter and Mathe were among the few honest root and herb doctors hoping to help their fellows.

You open the book to a page you had marked, sneezing and sniffling as you do so.  You read the passages you were looking for.
ASTHMA OR PHTHISIC.
This complaint is a spasmodic affection of the lungs, which mostly comes on by paroxysms or fits. It is attended with a short, difficult, frequent respiration, with a peculiar wheezing; there is also a stricture or tightness across the breast, which produces a peculiarly unpleasant sensation. Some have so light an attack of this disease, that they experience but little difficulty from it except when they take cold. Others are never entirely clear of its symptoms. Those who are afflicted with this complaint, experience an increase of the symptoms in the evening, and during the early part of the night. Towards morning the symptoms suffer some abatement-; sometimes enough to let the patient get some sleep, but the patient cannot lie down, without increasing the difficulty of breathing, and suffering a sensation similar to suffocation. This complaint is so easily known, that we deem it unnecessary to add any thing more on the symptoms.
TREATMENT
This distressing complaint has long been numbered with those that could only be mitigated, and not cured; but the introduction of the botanic practice has stripped this disorder of its wheezing terrors, and offered the afflicted asthmatic a relief from this suffocating torture. In the whole compass of medicine there are but two articles yet discovered, that are very useful in this complaint, or deserve any thing like the character of being specifics for it; and these are botanic remedies.
The tincture of lobelia, given in doses of a tea-spoonful twice a day, or the pulverized lobelia given in doses of from half to a whole tea-spoonful, once a day, has been found almost a specific for this disorder. In some eases, the pulverized root of skunk cabbage, administered in doses of a half or a whole tea-spoonful mixed with honey or melasses, and repeated as the symptoms may require, often gives relief, in some kinds of asthma when the tincture does not effect a cure. It acts both as arc expectorant, and anti-spasmodic, which gives it a peculiar advantage in some cases of this complaint; yet in most cases, the tincture of lobelia is the surest remedy. In severe cases of long standing, it will be necessary in addition to the above, to carry the patient through several courses of medicine, at least one a week until a cure is effected. It will be necessary for the patient to make a daily use of some diaphoretic tea during the whole time he is using other remedies. He will facilitate the restoration of health and vigor, by using the astringent and bitter laxative tonic powders; and if his bowels ire incline to be costive, give him the stimulating tonic clyster occasionally to keep them regular.
Next to the book are the boxes containing the ingredients.  You prepare them, ingest, and wait.

What would it be like to have asthma on the American Frontier in 1837?" Sometimes it's good just to let our imaginations run wild.

References:
  1. Carter, J.E., A.H. Mathes, "The botanic physician, or family medical adviser:  being an improved system, founded on correct physiological principles comprising a brief view of anatomy, physiology, pathology, hygiene, or art of preserving health: a materia medica, exclusively botanical, containing a description of more than two hundred and thirty of the most valuable vegetable remedies: to which is added a dispensary, embracing more than two hundred recipes for preparing and administering medicine.  The diseases of the United States with their symptoms, causes, cures, and means of prevention.  Likewise, a treaties on the diseased peculiar to women and children," 1837, Madisonville, Tennessee, Published by B. Parker and Company
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Wednesday, August 24, 2016

1835: Ramadge's inhaling tube for consumption and asthma

Figure 1 -- Ramadge Iinhaling Pipe (1, page 93)
Respiratory therapists are well aware of insentive spirometers (IS) and positive end expiratory (PEP) therapy. You might think these are modern inventnions. You would be wrong.

Incentive Spirometers are small, hand held devices that that encourage patients who are on pain medicine, or who had recent abdominal or chest surgery, to take deep breath and cough to facilitate movement of secretions, thereby preventing or treating atelectasis and pneumonia. The incentive spirometer was invented in 1970 by R.H. Bartlett and quickly became an inexpensive mode of bedside therapy.

PEP therapy involves having the patient blow through a resistor that applies resistance, or positive pressure (usually 10-20 cwp), during expiration. The pressure acts as a splint to keep otherwise collapsible terminal airways and alveoli open. This facilitates the movement of secretions that would otherwise be trapped due to airway closure. It was invented in Denmark during the 1970s and was became popular in Scandanavia, Denmark and Canada before making its way to the United States. (5, page 1001)

So both IS and PEP therapy were invented during the 1970s and are forms of chest physiotherapy, or chest exercise through manual movement. However, the general concept was conceived of back in 1810 by a doctor by the name of Francis Ramadge.

He was a student of Rene Laennec, the inventor of the stethoscope.  The two men worked together in order to find a means of preventing people from developing consumption, the most common respiratory disease at that time.

Laennec suggested a natural cure for consumption was the formation of cicatrizations, or scar tissue, following the softening of the tubercles.  This scar tissue, he suspected, acted as a natural barrier against the disease. He suspected most people living with the disease had such scar tissue.

Ramadge, on the other hand, believed that since consumption resulted in a small, contracted and frail rib cage, anything causing the opposite effect prevented consumption. Various other physicians agreed with Ramadge. (1, pages 91- 93)  (3, page 8-9, 37)

Two such diseases suspected as acting as natural barriers against the disease, Ramadge suspected, were catarrh (colds) and asthma. He said:
For instance, let us begin with catarrh. Here tumefaction (swelling) of the mucous membrane preventing the free egress of the air, imprisons it in the air-cells, and produces a quasi emphysematous state of the lungs, expanding their entire volume to a certain degree, and pushing outwards in every direction the walls of the chest. Asthma also acts in a similar way. (3, page 8)
They believed if patients took care of their asthma this would act as a barrier to consumption. Ramadge said that this was one of the "ulterior good" effects of having asthma. It was "a lesser evil being substituted for a greater." (6, page 37)(1, pages 91- 93) (3, page 9, 37)

Ramadge also believed that any medical condition that impeded free expiration tended to "mitigate and arrest the disease."  Such conditions included: enlarged tonsils, tumors pointing towards the pharynx, polyps in the nasal passages, aneurysms of the aorta, diseases of the heart, obstruction of the liver, hysteria and pregnancy.  (3, page 8)

It was based on these theories that he invented what was called "an inhaling pipe," which would later be referred to as the Ramadge Inhaling Pipe.  He believed that by inhaling and exhaling through the pipe the patient would develop an expanded chest. In this way, regular use of the pipe had "palliatve and prophylactic, as well as a curative, intentions." (1, page 93) (3, page 10, 59)

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

The Ramadge Inhaling Pipe wasn't exactly PEP therapy, but the principle was similar.  He said:
The value of the tube in catarrh, which it supersedes as a curative agent, must not be overlooked. By due exercise and expansion of the bronchial ramifications, it contributes to allay, or indispose to, irritability of the lining membrane, and I have often heard patients state that after its use in the morning they have been better, and more freely able to bring up the accumulated phlegm. (3, page 59)
The inhaling pipe wasn't an IS, although it worked similarly to encourage deep breathing and coughing.

Ramadge said:
The lungs may simply and safely be kept in daily exercise, and expansion to the full amount may be effected by atmospheric inhalation, through the respiratory apparatus. (3, page 15)
Dr. Samuel Sheldon Fitch, in his 1847 book "Six lectures on the uses of the lungs," described the tube.  He said: (1, page 91-93)
This tube he at first made about four and a half feet long, with an opening through its whole length, provided with a mouth-piece to go between the lips, and the patient sucked in, or inhaled the air as long as he could, and then through the same tube, blew it out again. By this process, the chest would rapidly enlarge. Dr. Eamadge also made an inhaling tube a little like a whistle, with a valve in it so constructed that the air would go into the mouth and lungs through a large free passage, and on returning, the air would be forced to go outmof the mouth and lungs through a much smaller opening. The effect of which is, to allow the lungs to fill rapidly and without exhaustion of strength, and on leaving the lungs, it is all passed through an opening not much larger than a knitting- needle, by which the air was slowly forced out of the lungs, and by this pressure the lungs were greatly expanded, and the air every where opened the chest in the largest manner. (1, page 93)
Fitch said the tubes were made of wood or ivory, although he recommended they be made of gold, platina or silver so that they last long, and the patient can take the tube wherever he goes and can use it often to keep his lungs expanded.  (1,2)

Ramadge said he'd prefer his patients use the inhaling tube...
...but, in the absence of the inhaler, I have no hesitation in saying, on the Principle of choosing the minor of two evils, that exposure to the exciting causes of catarrh, under prudent restrictions, is an alternative that may be judiciously adopted in consumption. (3, page 15)
Surely there were other remedies for consumption, such as leeches, tonics, sedatives and relocation, but...
...The use of the inhaling tube I consider to be essential in the treatment of phthisis; indeed, all other treatment is comparatively secondary and ancillary. (3, page 10)
He said it worked even as a last ditch effort to save the life of a consmptive in the dire states of the disease.  He said:
It may be thrown out as a sheet-anchor, even at the eleventh hour. A clergyman's daughter, who had been despaired of, in phthisis, by several medical men, was induced, as a dernier ressort,to employ the inhaling apparatus for two or three months, during which period a decided retrogression of all her bad symptoms was established. Considering herself well, she left it off and died. It is not improbable that, had she gone on till her disease had been more completely brought. (3, page 59) 
While recommended for consumptive patients, he said his inhaling device also worked well for asthmatics.  He said:
In asthma the windpipe is too small for the volume of the lungs, and, though it may seem contradictory, the mechanical respiration by the tube has the effect of restoring this disturbed relation to its healthy standard. The objection to it, on the score that asthma is liable to be superinduced by its use, arises from idle prejudice. Could I but present one-tenth part of the cases which have been rescued from a premature grave, chiefly by means of using this instrument, I should force irresistible conviction on the most incredulous, or at least induce them to institute a number of experiments, patiently and judiciously, so as to satisfy themselves of the truth. (2, page 10)
Not sold yet as to the efficacy of the Ramadge inhalaing pipe?  Well, how about some endorsements that might change your mind.  Ramadge said:
This mode of treatment has many advocates, both in England and abroad. Lebeau, physician to the King of the Belgians, and senior surgeon of the Military Hospital at Brussels, as also Hohnbaum, physician to the Duke of Saxe Meiningen, and a distinguished pathologist, highly approve of it. Among the American medical men might be mentioned, the names of Drs. Pitch, Newton, and Hull, of Philadelphia, and several other distinguished practitioners of the same country, together with a great many continental physicians, all of whom have adopted its use, and are its zealous supporters. (3, page 11) 
Ramadge would go on to become a well respected physician who specialized in pulmonary disease, ultimately becoming senior physician to the Infirmary for Asthma, Consumption, and other diseases of the Lungs. He claimed to have had the advantage of over 30,000 cases of consumption in all its various stages. He said:
I have no hesitation in asserting -- in contradiction to the opinion of many medical practitioners -- that this disease when properly, judiciously, and skillfully treated, is a curable as any other disease, the curability of which is not dispute. (1, page iv)
The Ramadge Tube was recommended by physicians for pulmonary gymnastics and as a prophylactic therapy for consumption until better devices were invented at the turn of the next century. (4, page 228)

Further reading:
References:
  1. Fitch, Samuel Sheldon, "Six lectures on the uses of the lungs," 1847, New York, H. Carlisle, pages 91-93, 
  2. Laennec, Rene, "On Mediate Auscultation," 1827, London, T and G Underwood.  
  3. Ramadge, Francis Hopkins, "The Curability of Consumption: the reprint of a series of papers, presenting its most prominent and important practical points in the diagnosis, prognosis, and treatment of the disease," 1850, London, Printed by W. Clowes and Sons
  4. Tissier,Paul Lewis Alexandre, edited by Solomon Solis Cohen, "Pneumotherapy: Including Aerotherapy and inhalation methods," volume X, 1903, Philadelphia, P. Blakiston's Sons and Co., pages 227-230.  If the profession of respiratory therapy existed in their era, we would be reading their books.  However, as it was, their books were written for the medical profession.  For a more detailed description of any of the devices mentioned on this blog click on the links provided. Unless otherwise indicated, all material from this post was from Tissier's book. 
  5. Sehlin, et al, "Physiological Responses to Positive Expiratory Pressure Breathing:A Comparison of the PEP Bottle and the PEP Mask,"  Respiratory Care, August, 2007, Vol. 52, No. 8, pages 1000-1005
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Monday, August 22, 2016

1835: Ramadge renews interest in nervous asthma

A fit of asthma is like the suffocation caused by a noose.
Francis Ramadge said: "As the respiration becomes more 

difficult the pain at the chest increases, and the constriction
is at last so intense as to be compared by the sufferer,
to what might be supposed to arise from cords bound tightly
 around it. It heaves and dilates as if striving to burst these
 imaginary bonds, and is again compressed, as it were,
by their violent re-action.. after retiring early to bed..
.
the patient is suddenly awakened in a few hours 
by a feeling of strangulation, and finds that the fit has
seized him with all its violence. When fully awake,
 he finds an oppression of the chest, weighing him down 
like an incubus, and is constrained to sit up, 
or to quit his bed at once, if, as he imagines, 
he would escape suffocation." (6, page 43, 45)
By the end of the 18th century nervous asthma had gone out of fashion, becoming once again merely a form of dyspnea or a symptom of some other disease, such as bronchitis.   The idea that asthma was nervous in origin was not revived until the writings of Dr. Francis Hopkins Ramadge in 1835.  (1, page 599)

Ramadge was born in 1793 in Dublin, and was educated at Dublin college in London.  He received his bachelor's degree in 1816 and a master's degree in 1819 at Dublin.  He earned his medical degree at Oxford in 1821.  (3)

He was a student of Rene Laennec, the inventor of the stethoscope.  So he would have been well acclimated to this new tool.

He went on to become a well established physician in London, developing an "extensive" and "lucrative' practice that focused "chiefly" on diseases of the chest. (7, page 92)

He became senior physician to the Royal Infirmary for asthma, consumption, and other diseases of the lungs.  He as lecturer on the principles and practice of medicine and chemistry.  (3) (6, page iv, 64)

Ramadge published a book on consumption that was well received, and this inspired him to write a book on asthma called"Asthma, its species and complications, " which was published in 1835.  (6, page v)

He wrote that asthma was "less fatal (than consumption), it is true; but, when of an aggravated character, as exquisitely painful to the sufferer, as it is alarming to the beholder." (6, page v)

He said his book on asthma was necessary because...
...little has yet been done to put either the pathology, or the therapeutics of Asthma on a satisfactory basis. The few works of our English medical writers on the subject propose little beyond theory in the one, and palliation in the other. Nor have the labours of the continental physicians been much more successful. The views put forward, in this country at least, have been chiefly traced from the limited opportunities of private practice, for the most extensive are circumscribed, when compared with those afforded by a public institution. (6, page v-vi)
Of asthma, he observed what we already know:
Its Greek etymology (difficult respiration) is so comprehensive in its signification, that numerous disorders, distinctly separated from each other by their causes, and differing in their effects, have been classed under the name of Asthma, as a generic term, from then. agreeing in one general character—difficulty of breathing. This has not only produced much confusion among medical writers, but, as a necessary consequence, has led to a similar result in practice.
These are important statements made by Ramadge, because they show, as a pioneering physician of the scientific era, how vigilant he was of the theoretical basis of most conclusions regarding asthma prior to his era, and even during his era.

So he aimed to end this confusion, and he aimed to do it by using the one advantage he had over them: the stethoscope.

By using this new tool he was able to prove that bronchitis followed and did not precede a fit of asthma, and this, he believed, should disprove the bronchitis and humoral theories of asthma that postulated it was the result of inflammation and secretions in the lungs caused by organic lesions or, as Robert Bree speculated, some peccant matter that made its way into the lungs.

He did not deny asthma was humoral, yet he believed organic lesions were more likely to cause asthma in the extremes of life, such as in childhood from congenital abnormalities, and in adulthood from lesions of the large vessels and heart.  He said humoral asthma, when it did occur, was most likely in old age. (6, pages 9-10)

By using his stethoscope, he believed the following should not be considered forms of asthma, but disease entities of their own.  (6, page 10)
  • Structural impediment of the larynx that narrow the airway (6, page 10,33)
  • Structural impediments of the trachea that narrow the airway (6, page 10,33)
  • Extensive adhesion (6, page 10)
  • Emphysema of the lungs  (6, pages 10, 35-36)
  • Bronchitis, dyspnea with inflammation (6, pages 10,33)
  • Hydrothorax, edema of the lungs  (6, page 10)
  • Glandular or calcareous obstructions at the root of the lungs  (6, page 10)
  • Various organic lesions of the heart or aorta  (6, page 10)
  • Valvular irregularity of the heart or aorta  (6, page 10)
  • Ossification of the coronary arteries  (6, page 10)
  • Chronic pericarditis, (6, page 10)
  • Angina Pectoris, Darwin's asthma, Laennec's Neuralgia, chest pain, cardiac asthma (6, pages 18-33)
  • Pulmonary apoplexy (6, page 34)
  • Acute Catarrh, swelling of the air passages, nasal passages, etc. 
  • Etc. (6, page 10)
He believed that all of these could be distinguished from asthma simply by means of auscultation with a stethoscope and thorough assessment and questioning of the patient.  For example, when a patient complains of chest pain, or is yelling things like "My arm!  Oh, my arm!" a physician might think angina, not asthma, is the cause of the person's agony.  (6, pages 18-19)

He did, however, believe that any of these may lead to asthma.  He also beleived that asthma, when "long continued" may result in organic lesions that seriously affect a person later in life.   (6, page 36)

So, instead of thinking that asthma was humoral or bronchitic in nature, and in the absence of organic lesions, Ramadge postulated that asthma must be nervous in origin.

In order to allay some of the confusion regarding the term asthma, he decided that he needed to come up with a new term.  He therefore decided that nervous asthma was asthma in its pure form, was nervous or spasmotic or convulsive or idiopathic asthma.  Yet he preferred to refer to it as pure or essential asthma.  (6, pages 65-66, 92)

He believed a paroxysm of asthma occurred when some exciting cause, either internal or external, irritated the nerves, resulting in the brain sending messages along nerves supplying airway and pulmonary tissue, including the bronchi.  This message causes spasms of the trachea and bronchial tubes. (4, page 3)(5, page 193)(6, page 12)

He believed that essential asthma was caused by "some injury done to the nerves of the chest, by cold or other means.  He described a case of asthma that he suspected arose after a case of the hooping cough.  When this happens, the pneumogastric nerve, which supplies nerves to the throat and lungs, becomes damaged or irritated. (4, page 60-61)

Other exciting causes might include: 
  • Troubled mind or passions of the mind(6, page 19, 59)
  • Passions of the mind (such as fear, excitement)(6, page 86)
  • Irritable temperament (6, page 59)
  • Gusts of passion (6, page 19)
  • Excessive eating (6, page 11)
  • Excessive drinking (6, page 11)
  • Excessive anything (6, page 11)
  • Inhalation of occupational particles, metals, or dust (6, page 11)
  • Nervous temperament (6, page 11)
  • External irritants, such as strong smells like the smell of tea (5, page 193)(6, page 11)
  • Internal irritants, such as a visceral (organ) irritation, sympathetically affecting the brain, or a tumor in the lungs, or adhesions in the lungs.  (6, page 11)
  • Atmospheric influences, such as changes in weather; excessive heat at end of May, or  (6, pages 14-16)
  • Particular period of the year, such as winter or summer (this would be the most common in the purely nervous asthma; the most violent asthma occurs after the summer solstices) (6, page 46)
  • Stomach ailments (caused by food ingested, indigestion, dyspepsis, etc.)(6, page 83, 86)
He said pure or essential asthma caused morbidity, but did not, as a general rule, cause mortality.  He said:
The prognosis of asthma is seldom difficult.  Doubt can arise only in cases severely complicated. When asthma wears the purely nervous form, danger is rarely to be apprehended." (6, page 36)
However, he added:
"To sum up prognosis in a few words, asthma is seldom productive of present danger, but often betokens much future inconvenience."
He believed asthma was periodic, the episodes were generally short lived, and the intervals in between the fits were of varying lengths.  He also believed the person would experience perfect health between episodes. (6, page 17)

It was only when asthma was prolonged, or continued for a long time, that it might cause organic lesions resulting in such conditions as emphysema of the lungs, bronchitis, heart disease, or other diseases often confused as asthma.

Symptoms of essential asthma were: (6, page 45)
  • Difficulty in breathing (6, page 18)
  • A sense of suffocation (6, page 18, 43)
  • Pain across chest (6, page 43)
  • Flatulent uneasiness in the stomach and bowels (6, page 16, 46)
  • Undefined oppression and constriction of the chest (6, page 16)
  • Dry cough (6, page 16, 43)
  • General irritability (6, page 16)
  • General impatience (6, page 16)
  • Headache (6, page 16)
  • Dejection (6, page 16)
  • Langour (6, page 16)
  • Thirst and dryness of the mouth (6, page 17, 43)
  • Dry and cold skin (6, page 17, 43)
  • Copious flow of clear urine (6, page 17, 45)
  • Drowsy (6, page 42)
  • Disinclined to exertion (6, page 42)
  • Apt to fall into disturbed and uneasy slumber (6, page 42)
  • Wheezing on expiration (6, page 43)
  • Wheezing accompanies exertion, and is audible (6, page 43)
  • The sufferer literally gasps for breath (6, page 43)
Similar to those who support the humoral or bronchitic theory of asthma, such as Bree, Ramadge believed the fit of asthma usually ended with the expectoration of sputum. (6, page 17, 46)

He believed that pure asthma was a rare condition.  (6, page 103) 

He even speculated as to which folks were most likely to acquire disease:
The predisposition to asthma is very generally apparent, in individuals of a defective constitution, and morbid temperament. In numerous instances, it may be traced to the transmission of the nervous susceptibility of receiving impressions, injurious to the respiratory functions, from parent to child. How frequently indeed do we see a kind of general disposition handed down, from one generation to another; sometimes immediately, at others with the intermission of one, or more generations. And we frequently find that the more intimate the moral, no less than the physical organization of two individuals, the one in the ascending, the other in the descending line; the more probable is it, that the latter will inherit the morbid peculiarities of the former. (6, pages 101-102)
He suspected asthma to be be hereditary.  He said he observed its occurrence in n four generations of one family.  He said the father had asthma, and three of his four children also had asthma. He said one of the daughters married, and, of her two children, one had asthma. The one who had asthma also had a child with asthma.  (5, page 190)(6, pages 56, 101-102, 104)

Ramadge wondered why the nervous theory of asthma fell out of favor among the medical community.  He blamed it on the fact that...
...from the time of Willis, who was the first to observe the nervous character of uncomplicated asthma, down to the publications of Laennec and Andral, no light has been thrown on the seemingly inexplicable disease from morbid anatomy.  All agree that it is impossible to discover any lesion; or from post-mortem examination to assign any cause for the presence of the disease. (1, page 92)
He added:
It is deeply to be regretted that our own writers on this disease should not have been more anxious to investigate its pathology, than their works would evidence. From many circumstances in cases detailed by them, I am induced to believe that many important states have been either overlooked, or misunderstood. Had due attention been given to the subject from Willis's time to the present, we should have had a rich harvest of facts on which to reason. As it is, we are presented with innumerable details, gleaned from the works of men who wrote at a period, when the art of minute dissection was in its infancy; and when, consequently, many appearances of consequence to a full understanding of the case must have escaped notice. (1, page 96)
Despite this work by Ramadge, it wasn't until 1851, through the prize winning work of Bergson and Lefevre , that nervous theory of asthma would be fully accepted by the medical community, and that asthma would be "recognized as an independent affection."  (1, page 599)(2, page 596)

He died 31 years later in 1867. (3)

References: 
  1. West, Samuel Hatch, "Diseases of the organs of respiration," volume II, 1902, London, Charles Griffin & Company, Limited 
  2. Whitaker, James Thomas, "The theory and practice of medicine," 1893, New York, William Wood and Company
  3. Gordon, Goodwin, "Ramadge, Francis Hopkins," from the "Oxford Dictionary of National Biography: 1885-1900," volume 47, Matthew, H.C.G., Brian Harrison, Lawrence Goldman, editors, http://en.wikisource.org/wiki/Ramadge,_Francis_Hopkins_(DNB00), accessed 2/10/14
  4. Schmiegelow, Ernest, "Asthma, considered specially in relation to nasal disease," 1890, London, H. K. Lewis
  5. Geddings, W.H., author of the chapter on "Bronchial Asthma," in the book  "A System of Practical Medicine," edited by William Pepper and Louis Star,Volume 3, 1885, Philadelphia, Lea Brothers and Co.
  6. Ramadge, Francis Hopkins, "Asthma, its species and complications, or researches into pathology or disordered respiration; with remarks on the remedial treatment applicable to each variety; being a practical and theoretical review of this malady, considered in its simple form, and in connection with disease of the heart, catarrh, indigestion, etc." 1835, London,  Longman, Rees, Orge, Brown, Green, and Longman
  7. Fitch, Samuel Sheldon, "Six lectures on the uses of the lungs," 1847, New York, H. Carlisle, pages 91-93, 
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Friday, August 19, 2016

1835: Ramadge questions that Dr. Bree had asthma?

So we know that Dr. Robert Bree published a book called "A Practical Inquiry into Disordered Respiration" that became the principle authority on asthma during the first half of the 19th century. Yet his book did not come without criticism.  

George Lipscomb, a fellow British physician, had the nerve to criticize Dr. Bree's ideas regarding asthma even as the book was first published.

Then, in 1935, Dr. Francis Hopkins Ramadge, in his 1835 book "Asthma, its species and complications," went almost as far as to suggest that Dr. Bree did not have asthma at all, and, therefore, was probably describing some other disease.  

He said: 
Dr. Bree delineated the early stages of his disorder, as distinctly as the latter, I have no doubt it would be found, that his asthma supervened upon latent consumption. Thus he gives no account of the symptoms preceding dyspepsia, which would have indicated, at once, the origin of his complaint. But, it is evident that some ailment of the chest was early at work, from his alluding to pain of the intercostal muscles, which could hardly have existed without; or, the reverse might have happened, and the dyspepsia impairing his health, have thus indirectly originated the pulmonary affection. (1, pages 135-136)
Some remarks of Laennec coincide wonderfully with this view of the case. He observes, "that nervous symptoms may mask phthisis for a long period; and that he has known it concealed for years by habitual dyspepsia, and other symptoms of hypochondria." (1, page 136)
This, in fact, is giving in other words the commencement of Dr. Bree's case, as stated by himself. So strongly, indeed, am I convinced that one or other of these explanations will apply to the learned Doctor's case, and elucidate what has been omitted by him, that, could he be induced to summon up his recollections, and retrace minutely the precursory symptoms of his disease, it would, I have little doubt, appear that either before, or during his dyspeptic condition, he had had attacks, slight ones perhaps, of haemoptysis. However, for an author to retrace his steps, crossexamine himself, and confess his views to be erroneous, would be an effort of candour above the powers of poor humanity! (1, pages 136-137)
I would not be supposed to insinuate, that any thing was purposely omitted by him. On the contrary, I believe he has detailed, and fully too, every symptom he conceived to be of importance; and that, supposing he had laboured under slight spitting of blood, he would have deemed it too irrelevant for notice. The course, therefore, of his complaint, on the supposition of the correctness of the views above taken, would be that on the appearance of the dry form of asthma, which did not exhibit itself for several years after the first manifestation of dyspnoea, his lungs became emphysematous, and the cavity, which I conjecture to have previously existed, was gradually healed up. The care he appears subsequently to have taken of himself put a stop to the bronchial affection, and with it of the asthma,which at one period seems to have been habitual with him. (1, pages 137-138)
Dr. Ramadge, along with other physicians who came to the same conclusion about Dr. Brees ideas regarding asthma, said that Dr. Bree was a smart man who, if he had had access to the stethoscope of Dr. Rene Laennec, would have easily seen his mistake.  

About twenty years later Dr. Henry Hyde Salter, who we will come to know as the author of the most famous asthma book of the second half of the 19th century, also criticized Dr. Brees ideas regarding asthma. 

Dr. Bree argued in favor of the bronchitic theory of asthma.  He believed the spasms or convulsions associated with a fit of asthma are all a part of the bodies effort to get rid of some irritating or peccant matter that was inhaled into the air tubes.  

I know I quote Dr. Salter's criticism of Dr .Bree in another post, yet I think it's worth repeating here.  Dr. Salter said: 
Dr. Bree maintains his argument with a great deal of ingenuity, and presses many facts into the service of his theory; but the most superficial reflection would suffice nowadays to show that it is utterly untenable ; and had Dr. Bree enjoyed the light that now shines on us from those two important points, the stethoscope and our acquaintance with excito-motory action, he would never have broached the doctrine he did: the one would have shown him the fallacy of his views, the other would have opened to him a solution of his difficulty—the stethoscope would have shown him that the conditions of an extraordinary discharging power are not present in an asthmatic attack ; indeed, that the power of getting rid of anything in the lungs is very much diminished by it; and the knowledge of reflex nervous action would, in connection with anatomy, have displayed the true nature of the disease, and made all its discrepant and scattered phenomena conspire to the production of its true and simple theory. (2, page 5)
With all due respect to Dr. Bree, the same argument about "if he had access to the stethoscope" could have been made regarding any of the physicians who studied lung diseases during their careers.  

Still, the argument that Dr. Bree never had asthma at all, and that his book did not describe convulsive asthma but some other disorder of the lungs, was quite impelling.  

References: 
  1. Ramadge, Francis Hopkins, "Asthma, its species and complications, or researches into pathology or disordered respiration; with remarks on the remedial treatment applicable to each variety; being a practical and theoretical review of this malady, considered in its simple form, and in connection with disease of the heart, catarrh, indigestion, etc." 1835, London,  Longman, Rees, Orme, Brown, Green, and Longman
  2. Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment," 1882, New York, William Wood & Company; Dr. Salter's book was originally published in 1860, and was previously released as a series of articles during the course of the 1850s
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Wednesday, August 17, 2016

1835: Lefevre questions nervous theory of asthma

Amedee Lefevre (1798-1869) was yet another physician who believed in the spasmotic and nervous theories of asthma.  Yet while he believed asthma was nervous, he was not prepared to deny there weren't organic lesions as yet discovered in asthmatic lungs. (1, page 505)(2, page 23-24)

Orville Brown, in his 1917 book," said Lefevre was an asthmatic who observed by studying his own asthma that he expectorated large amounts of sputum. (3, page 31)

Of this, J.B. Berkart, in his 1878 book, said: 
Lefevre (in 1835)... reverted to the opinion of Laennec. Himself an asthmatic, he had watched his own case and that of a friend, and arrived at the conclusion that the dyspnoea could be produced only by a bronchial spasm. In looking thus upon asthma as a nervous affection, he still was not prepared to deny the possible existence of organic lesions; adding, however, that if such were present, they were of so fleeting a nature as to elude detection. The essence of the disease he considered to be an increased irritability of the nerves of the lungs, in consequence of which the slightest irritation applied to the bronchial surface induced spasm of the bronchial tubes. (2, page 23-24)
However, Berkart suspected that the patient's he was studying were not asthmatics, and therefore his experiments (of which he performed with  Joseph Bergson) did not support his theory that asthmatic lungs might possibly have organic lesions.  He said: (2, page 24) 
The cases, however, which he himself reported, do not confirm his views. It is difficult to recognise a nervous affection, much less a bronchial spasm, in the dyspnoeal attacks, which terminated always with the expectoration of thick masses of mucus. The expectoration was of a grey colour, very viscid, in consistency like boiled maccaroni, filamentous in shape, and, when disentangled, appeared as if moulded to the bronchi. Sputa of that kind sufficiently distinguish the preceding dyspnoea as the symptom of a fibrinous (croupous) bronchitis, and there can be no doubt that Lefevre and his friend were subject to that disease. (2, page 24)
So while he thought he was on to something with his theories, he probably added little evidence to advance either the spasmotic nor the nervous theories of asthma. The reason was mainly due to the inability to differentiate bronchitis with asthma.

Of interest is he also observed spirals in asthmatic sputum.  This would be an observation that would inspire investigations by later physicians that would ultimately lead to a new theory about asthma.  (1, page 505)

He also wrote a book called De 'lasthme , of which you can read if you can read French.  

References:
  1. Sakula, Alex, "Charcot-Leyden crystals and Curschmann spirals in asthmatic sputum," Thorax, 1986, 41, pages 503-507
  2. Berkart, J.B., "On Asthma: It's Pathology and Treatment," 1878, London, J. & A. Churchill; The reference used by Berkart is as followed:  "Recherches sur l'Asthme, M&noire couronne' par la Society de MfSdecine de Toulouse."—JournalHebdomad., 1835.
  3. 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; he refers to the same source as Berkart
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Monday, August 15, 2016

1823: More native American asthma remedies

John D. Hunter lived among the Indians and learned about their medicine through the normal course of life. There were many other "whites" like Hunter who lived among the Indians, some who were kidnapped by them as Hunter was, and others for the simple purpose of studying them as George Catlin did.

Virgil J. Vogel researched and studied their records and recorded a list of Indian remedies in his book "American Indian Medicine.

Some of these remedies as they pertain to our asthma and respiratory therapy history are listed here: :
  • Skunk Cabbage:  Mainly used for consumption more so than asthma, but it was used as an expectorant. In either case, the dried roots were used. Imagine a medicine man bringing you this stinky remedy and saying, "Well, eat up."   (2, page 207, 367)
  • Red Cedar Berries (perus virginiana) and Wild Ginger (Asarum canadense):  A "steeped infusion" of these was used by the Rappahannocks. (4, page 207)
  • Balsam Poplar:  It was turned into a salve that was inserted into the nares by the Pillager Ojibwas to relieve congestion caused by a cold (which would probably sometime be allergies).  It was used for colds, catarrh (a cold), and bronchitis. (2, page 276-7)
  • Indian Balsam:  (Balsam fir (Abies balsamea):  Vogel says that Hunter said it was good for colds, coughs, asthma, consumption. (2, page 277-8)
  • Corn oil:  Dr. D.C. Jarvis (1881-1966) wrote about folk medicine, and noted that corn oil was often recommended for hay fever, migraine, and asthma. (2, page 293)
  • Cottonseed oil:  Used in South Carolina and by the Mayans to treat asthma. (2, page 295)
  • Ginsing Root (Panax quinquefolius L):  It was often used as a panacea by the North American Indians, Europeans and the Chinese.  The French are known to have used it for asthma.  (2, page 307)
  • Green Helebore:  Used by the Iroquois to relieve catarrh. It was also used as a narcotic to treat asthma and other lung diseases.  It was also used to reduce heart rate and blood pressure.  (2, page 316)
  • Indian Hemp (Apocynum cannabinum L.): It's often used as a narcotic, and is the source of marijuana.  It made it's way to the United States and Europe to be included in asthma powders and cigarettes.  It was used by the Indians for asthma and whooping cough, although mainly because it "promoted perspiration." (2, page 319)
  • Indian Turnip:  Hunter says it was mixed with spikenard and wild licorice to treat a cough. It was also used for asthma, chronic catarrh, fever, and a variety of other ailments. An "Indian Doctor" by the name of John Briante said "the dried and pulverized root" was good as an expectorant, for asthma.  Dr. David Clapp (1811-1853) said it was good for asthma and chronic cough.  (2, page 322)
  • Jimson weed (Datura Strammonium):  The Rappohannock Indians of Virginia smoked leaves for shortness of breath.  It is similar to Belladonna, and was often used in folk medicine as a hallucinogenic and asthma remedy.  As it made it's way to America and Europe in the early 19th century, it was determined to have an alkaloid called Atropine in it that was a mild bronchodilator.  (2, page 328) Modern medicines such as Atropine, Atrovent, Spiriva are been derived from this plant, although many of the modern mediicnes are synthesized (made in a factory)
  • Mullen (Verbascum thapsus L.):  The leaves were smoked to relieve asthma and sore throat by the Mohegans and Penobscots.  The Catawbas "boiled het root and sweetened it to make a syrup for croup in children." The Creeks "boiled the roots with those of button willow for a drink used internally for coughs. The leaves were also boiled and the patient bathed in teh infusion while it was hot.  The Forest Potawatomis smoked the dried leaves for asthma, but Smith is uncertain whether they learned teh practice from teh whites or vice versa.  A smoke smudge was made of the leaves and the fumes inhaled for catarrh adn to revive an unconscious patient.  The Menominees smoked the root for pulmonary disease.  Smith said he had often seen whites smoke the leaves for asthma and bronchitis, and tehat the flowers were believed to be diuretic (good for heart failure) and had been used for tuberculosis."  (2, page 341)
  • Tobacco:  It was used (probably ingested) by the Maya for asthma, cough and headache, as well as a variety of other ailments.  Some considered it a panacea.  It was even used by some to treat bad breath.  Of interest to note is that while many people loved this panacea, Vogul writes that "The 'Counterblaste to Tobacco' of James I has been widely quoted for its quaint condemnation of smoking as a 'custome lothsome to the eye, hateful to the nose, harmefull to the braine, dangerous to the Lungs, and in the blacke stinking fume thereof, nearest resembling the horrible sigian smoke of the pit that is bottomlesse.'"  Vogul also notes that the "Menominees inhaled tobacco smoke to induce a narcotic state.  The blowing of tobacco smoke into the ear for earache was reported in this century among the Chickahominys, the Mohegans, and the Malecites... Louisiana Choctaws blew tobacco smoke on snakebites."  So tobacco was used as early inhaltions and fumigations of sorts.  (2, page 380-385)
  • Wintergreen:  It was made into a tea and used as a remedy for asthma.  It was also used for "coughs and diseases of the breast," according to Dr. Clapp.  (2, page 394)
  • Balsam of Copaiba:  It was used as an expectorent and diuretic
  • Balsam of Tolu:  It was used as an expectorant.  Vogul also notes that "In 1822 Dr. Bigelow called it useful in chronic bronchitis, asthma, and catarrh." 
So there's a small sample of some of the remedies that were used by native Americans, many of which made their way to the American and European pharmacopoeia. 

References:
  1. Vogel, Virgil J. "American Indian Medicine," 1970, London, Oklahoma University Press
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Friday, August 12, 2016

1901-1920: Hay fever becomes allergy

Paul Portier
The term hay fever was used for the first time in medical nomenclature in 1812 by Dr. John Bostock to describe seasonal allergy symptoms associated with the hay season. The term had been used by lay people much longer than that. So, even while many physicians doubted it was an appropriate term, it stuck in medical nomenclature like gum on a little boy's shoe.

However, a series of discoveries shortly after the turn of the 20th century would introduce the world to a series of new terms, such as anaphylaxis, atopy, and allergy.

In 1901, the Prince of Morocco summoned two scientists, Paul Portier and Charles Richet, to study a sea anemones called the Portuguese man-of-war. Their job was to learn how to protect swimmers from its sting, which caused painful blisters. (1, page 608)

Initially, the two believed the painful blisters were caused by toxins from the animal's tentacles once they were entered into the skin of humans.  Back then vaccination was becoming a household name, and so the two set out to create an antitoxin vaccine.  (1, page 608)

Richet started the experiment by extracting toxins from sea anemones, and gave them in small amounts to test dogs.  After the initial injection they figured the dogs would develop antibodies that would protect them from a second exposure of the toxin.  In this way they would develop a natural protection against it, or prophylaxis.
Charles Richot
However, when they extracted the toxin of sea anemones and inserted it into test animals (dogs in this case), the reaction they got was the opposite of what they expected.  The first two doses did no harm to the animals, but subsequent doses caused many of the dogs to go into a state of shock, and most did not recover.  Richet and Portier determined the animals died due to the effects of the toxins.

Instead of prophylaxis The animals developed aniphylaxis, a new term devised by the two men.

It's time for some definitions:
  • Greek pro means toward or before
  • Greek phylaxis means protection
  • Greek ani means opposite or away
  • Prophylaxis means to add protection
  • Aniphylaxis means to cause harm
So, instead of protecting the animals from developing symptoms, they caused the symptoms.  The scientists learned that a "foreign protein" was transferred from the sea anemones to the dogs making them hypersensitive to that protein. (2, page 11)

Other scientists performed similar experiments and came to similar results.

Clemons von Pirquet
In 1906, an Austrian pediatrician named Clemons Von Pirquet observed many of his patients were hypersensitive to substances that didn't bother other people.  These normally innocuous (harmless) substances were pollen, dust mites and some foods.

The purpose of the immune system is to attack foreign particles that want to harm the human body.  Yet sometimes the immune system attacks allergens that are not meant to cause harm.  Von Pirquet and Schlick observed this, and they coined the term allergy to describe when the immune system causes harm.  (5, page 53)(3)

Once again a definition is in order:
  • Greek allos means other
  • Greek ergon means action or enery
  • Allergy means the immune system causes the opposite effect as its intention (causes harms)
  • Allergen means a substance or protein that may incite the allergic response hen a hypersensitivity is present
  • Hypersensitivity means over-reaction; a hyper-reaction of the immune system; as in when exposed to allergens (Dated to 1870s)(Dictionary.com)
Von Pirquet actually believed that asthma was an allergic condition, and curing this disease was only a matter of finding the right foreign proteins to inject. History would prove him right in juxtaposing asthma and allergies, yet wrong on the front of this leading to a cure.

Also in 1906, German physician Alfred Wolff-Eisner surmised that pollen is similar to the poisons of the Portuguese man-of-war in that it could trigger the immune response in some some people.  By inserting drops of pollen into the eyes of volunteers, he was able to produce the same response suffered "during the hay fever season: red, swollen, and itchy eyes." He published his findings in 1906.  (5, page 54)

Thanks to Wolffe-Eisner's discovery linking hay fever with the immune system, hay fever was no longer believed to be a nervous disease.  It as no a disease caused by a hypersensitive immune system. This was an essential transformation because it would effect the future course of treatment for the disease.  Instead of seeking to alleviate a nervous disorder, the goal of treatment as not to fix a broken immune system.  (5, page 54)

In 1910 Samuel Melzer observed the "similarity" between anaphylaxis and asthma "in which a person became sensitized to a definite substance, and an attack occurred every time the substance entered the circulation (of that patient).  Minute quantities of the substance, if inhaled, would bring on an asthma attack." (2)

We now know that about 75 percent of asthmatics have allergies.  Yet we also know that many people have allergies and not asthma.  We also know that both conditions have been linked to the immune system and can be developed at any age.  Yet in 1906 scientists were at the dawn of such allergy wisdom.

Pirquot believed it was the body's response, not the foreign particles, that resulted in the allergic reaction. He listed as things that might cause this "hypersensitivity" as bee stings, mosquito bites, hay fever caused by pollen, and substances in certain foods such as crabs.

Soon thereafter Arthur C. Coca, founder of the Journal of Immunology, and Robert Anderson Cook, were attempting to understand studies regarding allergic conditions, used the term Atopy which literally means "strange disease."  They thought atopy should be used to describe hereditary hypersensitivities such as asthma, hay fever and eczema, and hypersensitivities that could afflict anyone should be referred to as anaphylaxis.

By 1919 two allergists, Cooke and Albert Vander veer, published the results of a study of 500 patients with asthma, hay fever, and other allergic diseases that confirmed that age old theory that these conditions were inherited and perhaps linked to other conditions.

Initially all prophylactic and anaphylactic reactions were referred to as allergies, as this as the recommendation of Van Pirquot.  He believed the two reactions should have a common name.  (3)

Yet ultimately it was learned that there were three conditions associated with hypersensitivities that didn't fit into this classification:  asthma, hay fever and eczema.  In asthma the hypersensitive response lead to constricted air passages, in hay fever it lead to a runny and stuffy nose, and in eczema it lead to red and itchy skin.

These three conditions -- asthma, hay fever and eczema -- are now often referred to as the atopic triad because in many individuals they come as a package.  One major difference between the atopic triad and anaphylactic reactions is that anaphylaxis can be induced in almost anyone, while the others occur in only a small percent (about 10 percent) of individuals and are quite often hereditary.  (4, page 608)

In subsequent years allergy was used to denote an immunal hypersensitivity or hyperresponsiveness to a foreign substance and atopy was used to denote the inherited conditions of asthma, hay fever and eczema.  Although, quite often the terms allergy, atopy and anyphylaxis are used interchangeably.

References:
  1. Klein, Jan and Vaclav Horejsi, "Immunology," 1997, page 608
  2. Brenner, Barry E, "Emergency Asthma," (ed. Barry E. Brenner), 1998, New York
  3. Ehrlich, Paul M., Elizabeth Shimer Bowers, "Living with Allergies," 2008
  4. Klein, Jan, Vaclav Horejsi, "Immunology," 1997, page 608
  5. Mittman, Gregg, "Breathing Space," 2007, New Haven, London, Yale University Press