Monday, January 23, 2017

1872: Wyman recommends mountainous hay fever vacations

Morrill Wyman (1812-1903)
(6, title page)
Victims of hay fever realized early on that severity of the disease was directly proportional to certain geographic regions. And for this reason one of the original remedies recommended by hay fever physicians was to vacation during the offending season. One physician to do extensive studies on the geographic effects of hay fever was Dr. Morrill Wyman.

Wyman was born in Chelmsford, Massachusetts, in 1812, the second son of Dr. Rufus Wyman, who was chosen in 1817 to be physician and superintendant at the Mclean Asylum for the Insane at Charleston (A branch of the newly founded Massachusetts General Hospital), where he worked for 17 years.  Morril's older brother was Jeffries,who likewise became a reputable physician. He also had a younger a brother Edward. (3) (6, page 6, 84)

Morrill and his brother Jeffery entered Harvard College together, both graduating in the year 1833. (3) (6, page 52)

After receiving his Harvard degree he worked as an assistant engineer on the Boston and Worcester Railroad.  He said the "open-air life" was beneficial to his health, and after a year he had the urge to return to medicine. (6, page 52)

He studied medicine with his father, and, in 1834, he became the medical student of Dr. William Johnson Walker, a physician and surgeon at Charleston and a friend of his father. He studied the books recommended to him, and tended to patients who came to Dr. Walker's office.  Occasionally he traveled with the doctor to his see his other patients. (6, pages 52-53)

In the meantime, he also attended classes at the Medical School at Harvard University.

Beginning in 1836, Morrill served for one year as house physician of Massachusetts General Hospital.  While they he worked under Dr. James Jackson and Dr. Jacob Bigelow.  At the time anaesthetics were being experimented with, so Dr. Wyman had an opportunity to participate in these experiments. He and the other house physicians experimented on themselves by inhaling the various anaesthetics to personally observe their effects. (6, page 54)

After this assignment, he returned to the university to complete his medical degree, receiving it at the same time as his elder brother in 1837.  (3) (6, page 53)

He then started a practice at Cambridge and became a surgeon.

Among his first interests was the ventilation of sick rooms and public buildings, and he would end up publishing an essay on the subject called "A Treaties on Ventilation." In 1846, the same year the essay was expanded and published into a 400 page book, he earned the Boylston medical prize for the essay. (3) (5) (6, page 57)

He observed that methods of opening the chest to remove excess fluid from it were unchanged since the days of Hippocrates.  The operation was difficult to perform, dangerous, and offered uncertain results.  In 1850 he introduced a procedure for removing excess fluid from cavities of the body, particularly the chest cavity, that was both safer and easier to perform.  (3)

His son, Morrill Wyman Jr., described the device as consisting "essentially of an exploring trocar and canula of a very small diameter fitted to an exhausting syringe." (6, page 58)

His first demonstration of this device was on a 39-year-old lady who presented with a respiratory distress and pain.  By auscultation and percussion he diagnosed her with pleurisy with effusion (fluid or pus from infection or cancer) in the pleural sac (the cavity the surrounds the lungs). (6, page 58)

After waiting several days and allowing for traditional treatments to be trialed, the patient's condition deteriorated to the point that it appeared she was going to die and a priest was called.  It was at this point it was decided for Dr. Wyman to tap the ladies chest to draw out the fluid with his new instrument (a procedure called thoracentesis).

Dr. Wyman described the procedure:
The patient was, with Dr. Homans' aid, seated in a chair inclined to the right and the body bent a little forward. An exploring trocar and canula one-sixteenth of an inch in diameter was then passed by me through the intercostal space between the sixth and seventh ribs (counting from above) midway between the spine and the line of the axilla; it was pushed steadily on until its point moved freely in the pleural sac; withdrawing the trocar, twenty ounces of straw-colored serum were allowed to flow. The canula was taken out; the pain was slight, the patient expressed herself as much relieved, and she was laid in her bed. Two days after the operation she had occasional paroxysms of dyspnoea, and at her earnest solicitation the same trocar and canula was passed near the same place as before. This time, the canula had fitted to it a pump, so arranged that fluid was continuously drawn through it without the possibility of the entrance of air, or any septic fluid. With this, ten ounces of clear serum were drawn with immediate relief to the patient. The recovery was steady; in about three weeks after the operation she was about the house; a fortnight later she drove ten miles in a carriage, and was soon no longer under medical observation. (6, page 60)
The treatment was a success, and the lady survived.

Dr. Henry Ingersoll Bowditch (1808-1892)
He was an ardent abolitionist
who prayed for the end of slavery
and for the forgiveness of slave hunters.
During a second second case Dr. Wyman performed his procedure on a patient of Dr. Henry Ingersoll. Bowditch, which was also successful.  In 1851 Dr. Wyman and Dr. Bowditch read papers to the Massachusettes Medical Society on the successful results of 39 successful operations they both performed using Wyman's new method of thoracentesis.  (6, pages 64-65)

These two physicians proved the simplicity and safety of the new method, and soon thereafter gained the confidence of the rest of the medical community.

Wyman became particularly interested in hay fever, which he referred to as "autumnal catarrh" in 1833 when he first had a severe attack of hay fever, the same ailment his father, brothers, and later his son (Morril Wyman Jr.) suffered.  So he had ample reason to partake in a study of the aliment and, ultimately, publish a book on the subject.  (1, page 174)(2, page 18) (6, page 82)

Yet such research would be delayed due to his busy career and the Civil war. Prior to the ware he was a strong supporter of President Abraham Lincoln, and did whatever he could to support the Union.  (6, page 75)

He offered his services as a surgeon, but governor Andrew said his was needed at home.  A short while later, however, he was requested to serve on the U.S. Sanitary Commission, and his role was to inspect army medical facilities to make sure they were sanitary. (6, page 77)

It was only after the war that his interests in hay fever peeked.  Yet he didn't have to start from scratch, as his father had gathered some data on the subject.  (1, page 174)(2, page 18)

He was determined that "autumnal catarrh" was caused by the pollen from ragweed, and so he collected data from various correspondence to determine where the disease was most common. He published the results of his findings and his opinions on autumnal catarrh in his most famous book in 1972 book aptly titled "Autumnal Catarrh."

He wrote that the results of his studies proved that hay fever was both seasonal and geographical.  
Dr. Wyman interviewed patients who noted they had no symptoms
of hay fever while vacationing at resorts in the White Mounntains.
Partly due to Wyman writing about it in his 1872 book "Autumnal
Catarrh," the White Mountains became an elite hay fever resort area.

For instance, he noted that people who suffered from hay fever in May in the United States may have no symptoms while vacationing during May in Great Britain, and vice versal.
This, he said, was ample evidence that different geographic regions have unique causes of hay fever.

This is a map of the White Mountain region from Dr. Wyman's book.
 The uncolored areas represent regions safe from Catarrh.
So, for this reason, he suspected a vacation to the opposite country may actually provide a remedy for the hay fever. (1, page 58-61, see also pages 1-6)

Wyman said: 
It may be assumed, therefore, with a good degree of certainty, that the Autumnal Catarrh of the northern portion of the United States does not exist in Great Britain, nor in those countries on the Continent above mentioned. To this we may add, that although Dr. Phoebus makes mention of asthmatic and catarrhal attacks occuring in these countries annually, at other seasons than early summer, he makes no mention of a regularly recurring catarrh in September. He gives the average duration of the June Cold as about eight weeks. (1, page 61)
Wyman also observed that hay fever...
...does not exist over the whole United States. It is a matter of difficulty to give the exact limits the number of cases not being sufficient for that purpose. We can, however, arrive at proximate results which further observations may render more definite. We have no other evidence of its non-existence in the indicated places than this, that certain persons who have suffered elsewhere have ceased to suffer on removing to them. (2, page 61)
Using data he collected, he was able to create various pollen maps of the United States showing hay fever sufferers the best places to plan their hay fever vacations.  (You can view the maps here, click and scroll up one or two pages).

He believed places with low pollen counts would end an attack within 24 hours, or prevent one from occurring altogether.  Such locations were:  (1, page 73)
  1. Along the shores of Lake Michigan
  2. Canada
  3. Latitude 35°
  4. Extreme east of the continent
  5. Pacific coast.
  6. In the sea
The best methods of escaping the pollen, and the hay fever, were: 
  1. Sea voyage: symptoms do not seem to occur out at sea (1, page 73-4)
  2. Sea side:  Sea air seems to provide relief from hay fever symptoms.  If symptoms occur they are generally milder, and the cooler air is soothing and provides better ability to deal with symptoms. (1, page 74-9)
  3. Islands: They are protected by sea air, which seems to provide relief (1, page 74-9)
  4. City residence: It provides relief, but it is never complete, especially if there are fields nearby, or if there is a wind.  Although, for the most part, there is less vegetation in the city.(1, page 80) 
  5. Mountains:   Generally, the disease does not exist in places that are 800 feet above sea level. (1, page 81-95)
The only time the above may result in hay fever symptoms was when, as noted, the wind was blowing.  When this occurred, pollen from fields would waft to these regions, thus increasing the risk of hay fever symptoms.  

To further explain this, Dr. Wyman quoted Dr. Phoebus:
"Moist air brings to many, probably to most, great relief. Many praise the sea air. It brings a quick and lasting amelioration during the whole attack, even without sea bathing, which is also useful. Dr. Bostock proved this in his own case. Many reside at the sea-shore, or cruise about in yachts during the critical period. The asthma is immediately relieved at the sea-coast; but if the wind blows from the land, even for a single hour, the disease immediately returns." (1, page 79)
Dr. Wyman was not the first physician to propose the benefits of mountainous air for treating diseases, as tuberculosis had long been treated this way.  Likewise, for many years hay fever sufferers had noted to their physicians that they felt better when they traveled into mountainous regions. Dr. Wyman was, however, probably the first to make light of this observation, thus inspiring him to further question his patients.

The Glenn house was one of the earliest resorts in the White
Mountain region.  The original hotel was built in 1851, an expansion
 of an old farm house.  The name Glenn House was established in 1852
after the hotel was sold to J.M. Thompson (see this link for more).
Wyman notes in his own biography that he too found that staying
at the Glenn house offered him the most relief.  (1, page 173)
One of the hay fever sufferers he talked to was a lady from Lynn, Massachusetts. Wyman said:
She had suffered severely, especially in the asthmatic stage. She accidentally noticed, in 1853, while traveling in the White Mountain region, that her catarrh, which for twelve years had commenced in August 20th, had failed to make its appearance. The following year she visited the same region before the usual time of attack, with the hope of escaping it. She did escape it. During the remaining ten years of her life, until 1864, she was at the Franconia Notch, White Mountain Notch, or at the Glen House (a White Mountain resort established in 1851.  You can read about it here), — most of the time at the latter place. During this whole period she,obtained complete relief. (1, page 81)
Image of Wyman used in his obituaries in 1903. 
Another patient he talked to was Jacob Horton.  Wyman said:
In 1860, Jacob Horton, Esq. of Newburyport, Mass., who bad suffered so severely that he was obliged to keep his room during much of the attack, to answers to my inquiries replied: "The only relief for me is at the White Mountains."  (1, page 81-82)
So, it was by questioning his patients that he realized mountainous regions worked to the benefit of hay fever sufferers, and his further investigations verified his theory.

Places that he recommended were: (1, pages 85-89)
  1. White Mountains in New Hampshire
  2. Mount Mansfield in Vermont, one of the Green Mountains
  3. Slow Village near the foot of the Green Mountains
  4. Adirondack Mountains in northeastern New York State, including St. Lawrence and Chateaugay ranges
  5. The great Pennsylvania and Ohio plateaus (proves to be a good refuge)
  6. Catskill Mountain House 
  7. Alleghany Holds (only in certain plaes)
  8. Other, including regions not necessarily of high altitude (1, pages 85-89)
He said:
The large number of persons, who have visited these regions successfully, demonstrates their safety. But we have other evidence: persons who have left them before the end of the critical period, have been at once attacked, and the attack has ceased immediately on their return. (1, page 89)
The change in a sufferer fully under the influence of this malady, on arriving at the mountains is sudden and striking. His first night's sleep is refreshing, and in the morning his most annoying symptoms — the itching and watering of the eyes, the sneezing and nose-blowing, or the asthma — have much diminished. A second night gives still more relief and usually in the course of the following day most of the symptoms disappear. Besides this relief of the local symptoms, a still greater change takes place in the spirits. Activity of mind and body replaces discouragement and weakness, the usual flesh and strength are regained, and the sufferer feels assured that he has at last shaken off his enemy. 
(1, page 90)
The number of cases obtaining this relief in certain regions is too great to be explained by coincidence; the repetition, year after year, of the same relief at the time of arrival in such regions, is conclusive that the relief is connected closely with the arrival; that the causes of the disease, whatever they may be, have ceased to be efficient. We have no evidence that persons, residents of these regions, suffer.1 We have also the still further evidence that it is not dependent upon simple change of residence, for very many of those who are relieved in these regions have tried various other places without success; and yet these places, by their distance from their usual residence, and different physical conditions, should have afforded relief, provided ordinary changes alone were required. They have also tried various kinds of drugs, and different methods of medical treatment, with as little success. 
And he concluded by saying:
We are forced to the conclusion, then, that the causes of a paroxysm of disease which exist elsewhere, are less active, or entirely wanting in the places above mentioned; and that those who visit these places in due season, are for the much larger part greatly relieved, or entirely free. (1, page 92) 
Dr. Wyman was not the first to recommend mountainous regions as the cure for maladies, but he was the first to recommend them for hay fever sufferers.  He was the first to create maps showing ideal places of refuge for hay fever sufferers.

Still, his favorite place to recommend was the White Mountains. Partly due to the publication of his book  "Autumnal Catarrh" in 1872, the While Mountains became a prime location for hay fever vacations, thus becoming a prestigious mountain resort.

In fact, it was partially, if not significantly, because of his studies that the White Mountains became one of the most sought after vacation spots for hay fever sufferers, especially for those with money (such as hay fever doctors with the affection).

After serving as a physician in Cambridge for greater than 60 years, he announced in 1902 that he was no longer fit to see patients.  He passed away in Cambridge at the age of 91 in 1903. During the course of his life he saw Cambridge grow from a small town to a city, while himself becoming one of the most famous physicians in the United States. (3) (5)

Further reading:
  1. 1872: Wyman's two types of hay fever
  2. 1872: Good times for hay fever sufferers
References:
  1. Wyman, Morrill, "Autumnal catarrh," 1876 (first edition 1872), New York, Hurd and Houghton
  2. Mitman, Gregg, "Breathing Space," 2007,
  3. Walcott, H.P., "Fruitful career: sketch of the late Dr. Wyman by Dr. H.P. Walcott-- his professional and public service," The Cambridge Tribute, Saturday, June 27, 1903, page 9, accessed from Cambridge Public Library, http://cambridge.dlconsulting.com/cgi-bin/cambridge?a=d&d=Tribune19030627-01.2.93#, accessed 9/12/14
  4. "Morrill Wyman, M.D.", 1863, Cambridge Historical Society, https://www.flickr.com/photos/38861678@N03/3781219724/, accessed 9/12/14
  5. "Dr. Morrill Wyman Dead: One of the Most Famous Physicians in the United States Passed Away in Cambridge Aged 90," Boston Daily Globe, 1903, January 31, http://omeka.lts.brandeis.edu/items/show/885, accessed 9/12/14
  6. Wyman, Morrill Jr., "A brief history of the lives of Rufus Wyman (1778-1842) and his son Morrill Wyman (1812-1903)," Cambridge, Fourth March, 1913, privately printed
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Friday, January 20, 2017

1872: George Catlin describes Native American Respiratory Therapists

George Catlin (1796-1872)
There are many people we can thank for preserving the history of respiratory therapy, and among them is Georgy Catlin.  He was a painter who traveled to North and South America taking portraits of Native Americans.

By living among them between the years of 1832 to 1839, he became an expert of sorts on their way of life.  Included among his wisdom was knowledge on their view on air and breathing. 

Along with making portraits of them, he recorded their habits and their rituals.  He noted that their view on medicine was not the same as ours, as the Indians essentially thought of medicine as a mystery.  So as they used the term medicine pipe, they were essentially saying mystery pipe, meaning they didn't know how it worked.

Catlin, in "Notes of Travels Amongst the North American Indians," said he observed that the Indians, in their savage state, were healthier and had fewer diseases  --- including weakness of the lungs, bronchitis, and asthma -- than people who lived in the civilized world.  He made a similar observation in his book "The breath of life, or mal-respiration."   (3, page 3, 73) John D. Hunter (3, page 342) and John Lawson (4, page 151)

Georege Catlin oil on canvas
portrait of native american
See-non-ty-a,
an Iowa Medicine Man
1844-45 (Wikepedia)
He said he decided to write "breath of life" because...
...I have visited 150 Tribes, containing more than two million souls; and therefore have had, in all probability, more extensive opportunities than any other man living, of examining their sanitary system; and if from those examinations I have arrived at results of importance to their health and existence of mankind, I shall have achieved a double object in a devoted and toilsome life, and shall enjoy a twofold satisfaction in making them known to the world; and particularly to the Medical Faculty, who may perhaps turn them to good account." (2, page 3-4)
Along with diseases being rare, he observed that fatal conditions of the lungs were rare among the savages and the animals that lived amid the wild -- dog, ox, horse, etc.  This was not true among civilized man.  Lung ailments, along with ailments of the spine and abdomen, were rarely heard of among savage people, while civilized people had an amalgamate of ailments, including a variety of diseases, and aches and pains.
  
The natives believed that breathing was essential to life, and of this Catlin said:
Per Catlin: "Shutyourmouth. " (2, page 71
Man's cares and fatigues of the day become a daily disease, for which quiet sleep is the cure; and the All-wise Creator has so constructed him that his breathing lungs support him through that sleep, like a perfect machine, regulating the digestion of the stomach and the circulation of the blood, and carrying repose and rest to the utmost extremity of every limb; and for the protection and healthy working of this machine through the hours of repose, He has formed him with nostrils intended for measuring and tempering the air that feeds this moving principle and fountain of life; and in proportion as the quieting and restoring influence of the lungs in natural repose, is carried to every limb and every organ, so in unnatural and abused repose, do they send their complaints to the extremities of the system, in various diseases; and under continued abuse, fall to pieces themselves, carrying inevitable destruction of the fabric with them in their decay.... The two great and primary phases in life and mutually dependant on each other, are waking and sleeping; and the abuse of either is sure to interfere with the other. For the first of these there needs a lifetime of teaching and practice; but for the enjoyment of the latter, man needs no teaching, provided the regulations of the All-wise Maker and Teacher can have their way, and are not contravened by pernicious habits or erroneous teaching... If man's unconscious existence for nearly one-third of the hours of his breathing life depends from one moment to another, upon the air that passes through his nostrils; and his repose during those hours, and his bodily health and enjoyment between them, depend upon the soothed and tempered character of the currents that are
passed through his nose to his lungs, how mysteriously intricate in its construction and important in its functions is that feature, and how disastrous may be the omission in education which sanctions a departure from the full and natural use of this wise arrangement? (2, page 15-16)
He observed that native American mothers closely watched the breathing of their infants, of whom rarely, if ever, passed from this life (In fact, Catlin quotes an Indian Chief as saying that it is rare that a child under the age of ten passes away.)  Catlin explained:
When I have seen a poor Indian woman in the wilderness, lowering her infant from the breast, and pressing its lips together as it falls asleep in its cradle in the open air, and afterwards looked into the Indian multitude for the results of such a practice, I have said to myself, "glorious education! such a Mother deserves to be the nurse of Emperors." And when I have seen the careful, tender mothers in civilized life, covering the faces of their infants sleeping in overheated rooms, with their little mouths open and gasping for breath; and afterwards looked into the multitude, I have been struck with the evident evil and lasting results of this incipient stage of education; and have been more forcibly struck, and shocked, when I have looked into the Bills of Mortality*, which I believe to be so frightfully swelled by the results of this habit, thus contracted, and practised in contravention to Nature's design
There is no animal in nature excepting Man, that sleeps with the mouth open; and with mankind, I believe the habit, which is not natural, is generally confined to civilized communities, where he is nurtured and raised amidst enervating luxuries and unnatural warmth, where the habit is easily contracted, but carried and practised with great danger to life in different latitudes and different climates; and, in sudden changes of temperature, even in his own house... The physical conformation of man alone affords sufficient proof that this is a habit against instinct, and that he was made, like the other animals, to sleep with his mouth shut—supplying the lungs with vital air through the nostrils, the natural channels; and a strong corroboration of this fact is to be met with amongst the North American Indians, who strictly adhere to Nature's law in this respect, and show the beneficial results in their fine and manly forms, and exemption from mental and physical diseases, as has been stated.
The Savage infant, like the offspring of the brute, breathing the natural and wholesome air, generally from instinct, closes its mouth during its sleep; and in all cases of exception the mother rigidly (and cruelly, if necessary) enforces Nature's Law in the manner explained, until the habit is fixed for life, of the importance of which she seems to be perfectly well aware. But when we turn to civilized life, with all its comforts, its luxuries, its science, and its Medical skill, our pity is enlisted for the tender germs of humanity, brought forth and caressed in smothered atmospheres which they can only breathe with their mouths wide open, and nurtured with too much thoughtlessness to prevent their contracting a habit which is to shorten their days with the croup in infancy, or to turn their brains to Idiocy or Lunacy, and their spines to curvatures—or in manhood, their sleep to fatigue and the nightmare, and their lungs and their lives to premature decay.
If the habit of sleeping with the mouth open is so destructive to the human constitution, and is caused by sleeping in confined and overheated air, and this under the imprudent sanction of mothers, they become the primary causes of the misery of their own offspring; and to them, chiefly, the world must look for the correction of the error, and, consequently, the benefaction of mankind. They should first be made acquainted with the fact that their infants don't require heated air, and that they had better sleep with their heads out of the window than under their mother's arms—that middle-aged and old people require more warmth than children, and that to embrace their infants in their arms in their sleep during the night, is to subject them to the heat of their own bodies; added to that of feather beds and overheated rooms, the relaxing effects of which have been mentioned, with their pitiable and fatal consequences. (2, pages 16-19)
He was actually onto something here that may have been proved in the modern world.  Many of the diseases and plagues that ail civilizations are of our own doing.  By taking children away from nature, their immune systems aren't exposed to microscopic forces necessary for maturation.  This results in diseases such as asthma, or so states the Hygiene Hypothesis and the Micro Flora Hypothesis.  Yet these are modern theories. Catlin came to this realization by his own observations, without ever having done any studies.

"Who ever waked out of a fit of the Nightmare in the middle of the night
with his mouth strained open and dried to a husk, not knowing when or
 from where, the saliva was coming to moisten it again,without being
willing to admit the mischief that such a habit might be doing to the lungs,
 and consequently to the stomach, the brain, the nerves, and every
 other organ of the system?"  It requires no more than common sense
to perceive that Mankind, like all the Brute creations, should close their
mouths when they close their eyes in sleep, and breathe through their
nostrils, which were evidently made for that purpose, instead of dropping
the under jaw and drawing an over draught of cold air directly on the lungs,
through the mouth; and that in the middle of the night, when the fires
have gone down and the air is at its coldest temperature—the system at rest,
 and the lungs the least able to withstand the shock. (2, page 21-22)
Like John D. Hunter, Catlin observed that sleep was essential to resting the lungs and the limbs from the labors of life.  While one is sleeping the breathing and the pulse is slowed.  Yet too much sleep is also bad. Catlin explained:
In natural and refreshing sleep, man breathes but little air; his pulse is low; and in the most perfect state of repose he almost ceases to exist. This is necessary, and most wisely ordered, that his lungs, as well as his limbs, may rest from the labour and excitements of the day.
Too much sleep is often said to be destructive to health; but very few persons will sleep too much for their health, provided they sleep in the right way. Unnatural sleep (due to sleep inducing drugs?), which is irritating to the lungs and the nervous system, fails to afford that rest which sleep was intended to give, and the longer one lies in it, the less will be the enjoyment and length of his life. Any one waking in the morning at his usual hour of rising, and finding  by the dryness of his mouth, that he has been sleeping with the mouth open, feels fatigued, and a wish to go to sleep again; and, convinced that his rest has not been good, he is ready to admit the truth of the statement above made.
Breathing with mouth closed is ideal  (2, page 22)
There is no perfect sleep for man or brute, with the mouth open; it is unnatural, and a strain upon the lungs which the expression of the countenance and the nervous excitement plainly slow. (2, pages 20-21)
So the Indians, at least according to Catlin, were very conscious of the importance of breathing and sleeping.  They must, in a sense, be considered among the first true respiratory therapists.

*Bills of Mortality are a means of keeping death statistics in the 16th, 17th and 18th centuries, and mainly started after the plague of London in 1592.  Statistics were generally taken every week in order to keep track of how many people died, along with the cause of death. Sometimes they also included the age of the deceased.  See figure here and here.  Bills of Mortality are believed to have originated due to the ideas published by John Gaunt of England in his 1662 publication "Natural and Political Observations upon the Bills of Mortality." The book is considered the "first book of vital statistics."  He learned that more boys were born than girls, and that by creating an accurate death count he could estimate the population.  This was, therefore, the "first step in the application of mathematical methods to the interpretation of statistics." Truly, however, the first people to keep track of such statistics were the ancient Hebrews and Romans. (5, page 273)

References:
  1. Catlin, George, "Manners, Customs, and Condition of the North American Indians," 1841,
  2. Catlin, George, "Breath of life, or mal-respiration and its effects upon the enjoyments and life of man," 1872, New York, John Wiley and Sons, Publishers
  3. Hunter, John D., "Memoirs of a Captivity Among the Indians of North America," 1823, London, Paternoster-Row
  4. Vogel, Virgil J., "American Indian Medicine," 1970, London, Oklahoma University Press
  5. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1922, Philadelphia, W.B. Saunders Company
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Wednesday, January 18, 2017

1871: Walshe creates new asthma theory

Dr. Walshe described paralysis of the bronchial
musculature, which was essentially emphysema.
 Other physicians also observed this, one such
physician being Dr Friedrich Gustav Jakob Henle
(1809-1885).  Dr. Orville Brown said that
Henle believed  "imperfect expiration
and stenotic sounds as evidence of a paralysis
of bronchial muscles."  (2, page 33)
After Henry Hyde Salter wrote his famous asthma book "Asthma: It's Pathology and Treatment," the medical community was all but convinced as to the validity of the nervous and spasmotic theories of asthma. So when Dr. Walter Hayle Walsh came up with a third theory, he faced an uphill battle to convince the medical community, and he knew it.  

Dr. Walshe was well aware of the writings of Dr. Salter, and he supported the great asthma doctor's asthma theories.  Yet after studying the work of Rene Laennec and other physicians, he believed there was enough evidence to suggest that asthma was sometimes caused by paralysis of the bronchial musculature.  

In his book 1871 book, "A Practical Treaties on the Diseases of the Lungs," Walsh explained how he formed his theory. 
Laennec ascribed the peculiar air-distension of the lungs, found in persons asphyxiated by the mephitic gases of cesspools, to paralysis of the vagi nerves; Mr. Swan noticed similar distension in animals whose eighth pair had been divided in the neck (tide Nervous Apnosa). In both cases the contractile force of the bronchial muscles, concerned in expiration, is more or less completely annulled.  (1, pages 555)
Dr. Friedrich Gustav Jakob Henle
(1809-1885) was another physician
who supported the idea of paralysis
of bronchial muscles. He believed
 imperfect expiration and stenotic sounds
were his proof.    (2, page 33)
Vagus is Latin for wandering.  Early Roman physicians must have been amazed how this long nerve wanders throughout the body, from the brain stem all the way down to the abdomen.  In between, it branches to various viscera, or organs, including the ears, heart, lungs, diaphragm, and stomach. For this reason they referred to it as the vagus nerve.

Today it's still referred to as the vagus nerve, although it's also known as the 10th cranial nerve, the pneumogastric nerve, nerve X, or the wandering nerve.  It's responsible for many of the involuntary functions of the body, including breathing.
This refresher in mind, let's allow Walshe to continue:
If then, as we have seen, there be motive to believe that true dynamic asthma depends, as a rule, on spasmodic action of the bronchial muscular apparatus, here are speculative reasons for presuming that paralysis of the apparatus (vagus nerve) may cause an exceptional variety of the affection. Clinically, too, we meet with examples of asthma in which the comparative facility of inspiration, and difficulty of expiration, coupled with the deficiency of the usual amount of dry rhonchi (wheeze), suggest of themselves the probable existence of a minus, rather than a plus, state of power in bronchial contractility. Possibly such cases are those habitually most benefited by strychnia and galvanism. (1, pages 555-556)
Of course, upon making this observation, Walshe was aware that Dr. Salter had already succeeded in convincing the medical profession of another asthma theory. He therefore knew it would be very difficult to change the mind of a dogmatic medical profession.  He said:
This view is, however, far from being unopposed. Dr. Salter, for instance, adopting the prevailing theory that the bronchial muscles "are not, because they can not be, muscles of respiration," refuses to admit a paralytic variety of asthma. There are many clinical facts, now taking rank as accepted truths, which were once said "not to be, because they could not be," on the assumption that the conventional physiology of the hour was true. It seems to be a law of nature, that, where circular fibres embrace a tube, they are designed to influence the movement of its contents; why should the bronchial muscles have been created on a different principle? Experientia Falax! Dr. Salter may urge. True; but experimenta fallaciora.  (1, page 556)
He is not saying that all cases of asthma are paralytic in nature, just some.  As Dr. Orville Brown reminds us in his 1917 book on asthma, Walshe "adhered... to the bronchiolar muscle spasm theory to explain most cases of the disease."  (2, page 33)

So he wasn't totally opposed to the conventional wisdom regarding asthma at the time.  (16, page 33) (20, pages 13-14) (25, page 11)

References:
  1. Walshe, Walter Hyde," A Practical Treaties on the Diseases of the Lungs," 1871, 4th edition, London, Smith, Elder & Company
  2. Brown, Orville Harry, "Asthma, presenting an exposition of nonpassive expiration theory," 1917, St. Louis, C.V. Mosby Company
  3. Thorowgood, John C., "Asthma and Chronic Bronchitis: A New Edition of Notes on Asthma and Bronchial Asthma," 1894, London, Bailliere, Tyndall, & Cox, pages 13-14)
  4. Thorowgood, John C., "Asthma and Chronic Bronchitis: A New Edition of Notes on Asthma and Bronchial Asthma," 1894, London, Bailliere, Tyndall, & Cox, page 11
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Monday, January 16, 2017

1870-1900: The Pneumatometer (Part II)

By 1903 there were various pressure devices used to provide positive pressure breaths for therapeutic reasons and for artificial respiration.  The devices were mainly operated by some form of physical labor, such as through pumps and bellows.  
Stoerk's Apparatus (Figure 30)
(1, page 211)

Please note that all of these apparatus's are described in a book called, "Pneumotherapy: Including Aerotherapy and inhalation methods," by Paul Lewis Alexandre Tissier, and edited by Solomon Solis Cohen.

Stoerk's Apparatus:  It allows for inspiration by positive pressure and exhalation through rarified (less oxygen that what's in the air) air.  Rarified air caused a sort of suction or negative pressure that caused a negative intrathoracic pressure that induced expiration.  (1, pages 211-212)

Unlike the other pressure devices, this one didn't require direct or physical depression of bellows or pumps, instead "compression is obtained by a change of level in the water in a system of communicating vessels, brought about by setting up an oscillatory movement which changes their relative positions (Fig. 30). (pages 211-212)

An oscillating motion was created by swinging it back and forth with your hand. So the oscillations cause positive pressure (condensation) to cause inspiration, and negative pressure (rarified air or suction) that caused expiration.  (pages 211-212)

Dorell's Residual Air Pump (1, page 213)
Dobell's Residual Air Pump:  The device was small and compact, and could be carried in your pocket.  (See figure 31) (1, page 213)

It's described as "kind of mask which isfitted to the front of the mouth and held in place with a ribbon which passes around behind the ears; the apparatus is provided with valves to embarrass inspiration while expiration remains free. As a result the intrathoracic air is rarefied, and at the end of three to six respirations the residual air is reduced to a minimum and the diaphragm attains its maximum elevation. The patient then inspires in ordinary air, and this inspiration being freer than he is accustomed to, he experiences a sense of increased comfort. The same manoeuver is repeated several times at each sitting. The apparatus is certainly ingenious, but there is no means of determining with accuracy the degree of success attained."

Water Engine Bellows (Figure 32)
(1, page 214)
Water Engine Bellows:  It's also referred to as The Water-blower or Double Ventilator of Geigel and Mayer. The container is made of sheet iron and is filled to two thirds of it's capacity with water.  The container is completely enclosed except for four openings at the top.  To of these openings communicate with room air.  One holds a meter to measure volumes.  The fourth opening is where the pressure escapes.  A tube is connected to this opening, and a rubber mask is connected to the opposite end.  (1, pages 213-215)

Bellows inside are operated by a crank. The principle is similar to the way water engine or gasometer is operated. The patient holds the mask over his face, and turns the crank  As the crank is turned pressure escapes through the fourth opening, and this caused inspiration.  (see figure 32)  (1, pages 213-215)
Dupont's Apparatus (Figure 35)
(1, page 216)

Dupont's Apparatus:  It's based on the principle of the Bunson water pump or aspirator, is inexpensive, allows for inspiration as deep as you desire, and can be used wherever there is a flow of water.  The pressure is regulated by a mercury pressure manometer. (1, pages 216-217)

Tissier said it was the best apparatus for the reasons indicated in the previous paragraph.  Rarification and compression of air is done simply by pumping a pump alongside the apparatus.  Pressure is determined by flow of water or by working a stopcock on the patient tubing.  (1, pages 216-217)

S. Solis Cohen's Double Apparatus:  This is combination gasometer (a container that stores gas)  and water pump and was created by the author of one of our other 19th century respiratory therapy books and the editor of of Tissier's book.  There were various advantages to this device: (1, pages 217-221)
  1. It corrects the flaws of the other pressure devices
  2. It is continuous in action and relatively compact
  3. The price is moderate
  4. It can be used by the patient at his or her home
Cohen's Apparatus (1))
The device was described as follows:   (1, pages 217-221)

"It is true that the degree of compression of the air is regulated by means of weights placed on the upper portion of the condensed-air cylinder, and that the degree of rarefaction is regulated by means of weights attached to a system of cords and pulleys by which the cylinder containing the rarefied air is raised; but the apparatus is operated and the pressure modification obtained by means of a double-acting bellows—so that air is drawn out from the cylinder which is to contain rarefied air and discharged into the outer atmosphere, while fresh air is forced into the cylinder intended for condensed air. Although one stroke of the footlever accomplishes both condensation and rarefaction, the two systems are independent, and there is no communication between the cylinders except through the air-passages of the patient. This is an extremely ingenious idea, which, in addition to the other good qualities of the apparatus, should insure its success."  (1, pages 217-221)

The Cohen's Apparatus was invented in 1883, and introduced to the medical community via the New York Medical Journal in the October 18 issue

I think these were all "ingenious" inventions meant to help people with breathing difficulty.  It would be another century before such devices were mastered and redesigned for patient comfort and convenience.

References:
  1. 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 296-224.  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.
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Friday, January 13, 2017

1870-1900: The Pneumatometer


Due to the perceived therapeutic benefits of pressure therapy, between 1800 and 1870 various apparatus's were invented to provide "pneumotherapy" for such conditions as asthma, throat edema, emphysema, bronchitis, or dyspnea caused by diphtheria(2, page 45)

If you were a physician at this time you saw before your own eyes the evolution of pressure therapy.  By 1903 pneumotherapy was mentioned in various medical books, although it was still "under-utilized." Paul Louis Alexandre Tissier's, in his 1903 text, "Pneumotherapy: Including Aerotherapy and Inhalation Methods and Therapy," provides a detailed description of pneumotherapy. (1)

He expains that the machines available provided pressure changes upon the respiratory passages (1): 
  • By inspiration of condensed air (we now call it positive pressure)
  • By expiration into condensed air (what we now call PEEP)
And the following methods decrease pressure in the lungs (1):
  • By expiration into rarified air (what we now call negative pressure)
  • By inspiration of rarified air 
Tissier described the following devices.  Most of them were used in the patient's home mainly by the patient placing a rubber mask over his face, although some may also be used by physicians as spirometers or to provide artificial respiration.  (1)

Hawke's Apparatus
1.  Hauke's Apparatus:  After a series of tests by Hawke from Vienna, it was introduced around 1870. (3, page 577)

It's basically a tank filled with water to supply pressure or rarified air upon expiration and inspiration as provided by a pump or bellows.  Rubber tubing connects from the tank to a rubber mask that fits over the mouth and nose, held in place by the patient. (1, pages 196-197)

Hauke recommended using this to offset the "dyspnea caused by diphtheretic laryngitis in which it was not always successful."  It was also used successfully for pulmonary tuberculosis and emphysema.  The problem with this device is there was no way of measuring breaths given  (1, pages 196-197)

Waldenburg's
Appartus
2.  Waldenburg's Apparatus:  The flaws with the Hauke design were corrected by Waldenburg of Berlin.  The 1873 model consists of two reservoirs of sheet iron, and an inner and outer cylinder, with the inner cylinder gliding on the outer one.  (1, pages 197-199)

A cap on the outer cylinder is 10 cm in height and wider than the outer cylinder.  The inner cylinder is moved up and down by means of weights and pulleys.  "Water is poured into the apparatus so that, when the inner cylinder is forced down into the outer cylinder, the apparatus is filled to the brim, the cylindrical cap at the top of the outer cylinder being destined to receive the water that overflows when the inner cylinder descends."  (1, pages 197-199)

Graduated scales allow for measuring volume.  A rubber hose is connected to a spun metal mask cushioned with rubber.  Both positive and pressure breaths can be given with the device, and the breaths can be measured "regularly and accurately."  In fact, the device could also be used as a spirometer to measure lung volumes.  (1, pages 197-199)

Figures 21 and 22
Air could be moistened and warmed by adding a wolffe bottle.  Tissier also notes that the "apparatus has been deemed worthy of detailed description, as it has probably been used more frequently than any other."  (1, pages 197-199)

The apparatus was later modified by Cube, Weil, Schnitzler, and other folks you'd be familiar with if you were a respiratory therapist in this era. (1, page 200)

As you can see by figures 21 and 22, some of these wouldn't be applicable for home use, and may even be too bulky and expensive even for hospital use.  

Apparatus of Finkler and Kochs:  "With this apparatus (Fig. 25) condensed air is forced into the lungs during inspiration, expiration being assisted by withdrawal of air from the lung." (1, pages 204-206)

Inspiration is basically caused by positive pressure, and expiration occurs by negative pressure or suction.  (1, pages 204-206)

Figure 25 --Apparatus of Finkler and Kochs
The device can also be used as a spirometer to measure forced expiratory capacity, or "the quantity of air that can be expired after the fullest possible inspiration."(1, pages 204-206)

Beidert's Instrument:  This is an interesting device that's designed similar to a musical instrument called the harmonica, "to one extremity weights are affixed...  it's walls are made of leather, air tight, and have a necessary strength to maintain their original form against overpressure of air." (1, pages 206-209)

The machine is operated this way:  "The machine is placed upright on the margin of a table, so that the tube will be in a groove cut into the wooden base, and the desired quantity of (iron) weights is fastened to the upper cover of the bellows. If the upper end is turned down, the weights will sink and the bellows will fill itself with air. The bellows is then turned back, while the patient compresses the rubber tube with his fingers until he is ready to inhale through the mouthpiece attached; he then gradually inhales the air as the weights compress the bellows. While the patient expires into the free air the bellows is filled again by turning, and the operation continued in this manner indefinitely." (1, pages 204-206)

Pressure can also be applied in the following manner:   "For expiration into rarefied air, the tube is compressed and the bellows turned weights downward; applying the tube to the mouth, the air passes from the lungs into the partial vacuum produced by the expansion of the bellows. The bellows filled with the expiratory air is emptied by turning, while the patient inspires air at the atmospheric pressure, and the operation is repeated." (1, pages 204-206)

It appears like it would be a lot of work, but if it made a person feel better, then it must have been worth the effort.  

Frenkel's Apparatus:  If you think the figure to the right looks like an accordion, you would be... wrong.  You sat with the apparatus on your lab, and between your palms.  You place the mask over your mouth and nose. 

The air is rarified when you pull the accordion out, and when the device is compressed the air is condensed.  So pulling the "accordion" out will cause expiration, and pushing it in will cause inspiration.  (1, pages 209-210)

Frenkel's Apparatus
In compliance with all pressure devices since the Hauke Apparatus, "on the margin of the apparatus is a centimetric measure to measure how many centimeters the wooden disks are separated or brought together." It is by this means that volumes can be measured.  (1, pages 209-210)

So it appears to have been a very interesting device, and perhaps the simplest and easiest to use.  It could easily be used at home by the patient whenever needed.  The device coule also be used at a doctor's office or hospital for artificial respiration in the case of asphyxia or poisoning.  It could also be used as a spirometer.  

So these were some of the first pressure breathing machines. While many people think such machines are a modern innovation, the concept has been around for over 100 years.  The main difference between now and then is we have the ability to tame electricity.

References:
  1. 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 296-224.  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. All of the material from this post is from Tissier's book unless otherwise noted in the above paragraphs. 
  2. Minnesota State Medical Society, "Transaction of the Minnesota State Medical Society," 1886, St. Paul, H. M. Smyth Printing Co. 
  3. Rose, A., "Treatment of Disease of Respiration and Circulation by the Pneumatic Method," New York, The Medical Record: A Weekly Journal of Medicine and Surgery, Edited by George F. Shrady, M.D., Volume 10, Jan. 2, 1875 to Dec. 25, 1875, New York, William Good and Co., page 577
  4. Foster, Frank, editor, "Practical Therapeutics," Volume I, 1897, New York, Appleton and Co., page 19
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