Sunday, September 13, 2015

1769: Dr. Rush writes about asthma in children

Benjamin Rush (1745-1813) was a strong 
advocate of bleeding, and surely he 
recommendedit as a remedy for asthma. 
 Even as his practice started to decline
near the end of his career, he still
insisted on prescribing it.   
Benjamin Rush added nothing new to our disease asthma, although by reading what he wrote about the disease we can gather a good idea of what it would have been like to live with asthma during colonial times in the United States, and what would be the treatment if you saw a licensed physician for it.

As a physician he would have seen many adults and children suffer from asthma, especially in an era when there were few physicians in America.  Yet in the summer of 1769 he was called to take care of many children who were afflicted with the disease, some of whom suffocated and died.  This caused him to take this disease seriously, and to form opinions of his own regarding the disease.

Rush was born in Byberry, Pennsylvania, on the eve of Christmas in 1745, to John Rush and Suzanne Hall. His parents emigrated to America from Oxfordshire, England, becoming Quakers and Baptists.   (1, page 3)

His mother had attended boarding school, and so she was well educated for a woman of this era. His father was a farmer, as were most of his ancestors. He died when Benjamin was only six-years-old, and at this time his mother placed him under the care of her brother, Dr. Finley, who became his teacher and advisor. It was by his uncle's influence that Benjamin became interested in medicine. (1, page 4)

Benjamin obtained a bachelor's degree at the college of Philadelphia. He studied under Dr. Redman for four years, and then attended school at Edinburgh where he obtained his medical degree. He then spent several years in Europe studying medicine and science prior to returning to Pennsylvania in 1769, where he opened a private practice and was appointed professor of chemistry at the College of Philadelphia. (2)

From this time on, the following is what he accomplished:
  • He became a very popular physician by attending to the poor
  • He became very popular for his skills as a professor
  • He published the first American textbook on chemistry
  • In 1773 he wrote essays for the patriot cause
  • In 1776 he was elected to attend the provincial conference to send delegates to the Continental Congress
  • He represented Philadelphia as a signer of the Declaration of Independence
  • In 1777 he was appointed surgeon general of the middle department of the Continental Army, although he ultimately resigned. 
  • When the war looked grim, he surreptitiously campaigned for the removal of George Washington as commander in chief. He was ultimately busted and confronted by Washington, and no longer participated in any activities regarding the war. 
  • In 1789 he wrote in favor of adapting the Federal Constitution
  • He was elected to the the Pennsylvania Convention, and he voted in support of the Federal Constitution
  • He was treasurer of the U.S. Mint from 1797-1813
  • He was a proponent for the abolition of slavery
  • He petitioned for a national educational system for both men and women
  • He petitioned for medical clinics to treat the poor
  • He was an advocate for bleeding in medicine, and utilized it for nearly every diagnosis, including asthma. 
  • He died April 19, 1813.  He was 68-years-old. 
  • Throughout his life, he was the most popular physician in America.  (2)
So not only was he a well respected professor and physician, he was an important founding father; he was an important figure in the establishment of the United States of America.

As far as medicine was concerned he was a strong supporter of the ideas of Dr. Thomas Sydenham, and even went as far to write the introduction to the American edition of Sydenham's book "The works of Thomas Sydenham" that was published in 1808.

As far as our asthma history is concerned, he wrote the following articles:
  1. An account of asthma, from an uncommon cause
  2. A dissertation on the spasmotic asthma in children
  3. An inquiry into the natural history of medicine among the Indians
"A dissertation on the spasmotic asthma in children," was published in the Pennsylvania Gazette in the winter of 1769.  It was basically a letter to Dr. John Millar about an epidemic of asthma that winter. It must have hit him hard to witness so many children suffer, and to watch as some died.   (2, page 1)

He said asthma was not well known among the populace of Pennsylvania, and that even the ancients knew little of it.  It was a condition that was either inflammatory or spasmotic, and usually associated with "particular climates or situations."  (2, pages iii, 2)

He said there were other names for it. The Irish called it the Hives "from the resemblance it bears to a disorder which prevails in Ireland of that name."  (2, page 2)

He said it presented with "difficulty of breathing... and other symptoms of oppression and disorder in the lungs."  Dr. Home of London, who was the first to give an accurate history of it, called it "the Croup, -- or Suffocatio Stridula, -- a name by which it is known in Scotland." (2, page 3)

He mentioned Dr. John Millar, who described an outbreak in England in 1755.  He described it this way:  (2, page 3)
Children at play were sometimes seized, but it generally came on at night; a child who went to bed in perfect health, walked an hour or two afterwards in a fright, with his face much flushed, or sometimes of a livid colour, -- incapable of describing what he flet, -- breathing with much labour, and with a convulsive motion in teh belly, the returns of inspiration and expiration quickly succeeding each other in that particular sonorous manner, which is often observed in hysteric paroxysms.  The child's terror sometimes augmented the disorder.  He clung to the nurse, and if he was not speedily relieved by coughing, belching, sneezing, vomitting, or purging, the suffocation encreased, and he died in the paroxysm. (2, pages 3-4)
He also published a letter from Dr. Haygarth to Dr. Smith, in which Dr. Haygarth said that Dr. Russel was the first to describe convulsive asthma in children in his book De Oeconomia Naturoe.  Dr. Russel is quoted to have written:
A Fever attends this disease with great remissions; but upon every fresh access, the respiration becomes very short and difficult; the child is forced to sit up erect in its bed, or to get up; when it cries, is very hoarse; but often makes, upon every inspiration, a shrill, skreaking, or clangose sound; and is if it is not instantly relieved by nature or art, must die. -- I have seen this distemper carry off, very suddenly, several children in a family. (2, pages 27-28)
Dr. Rush said that it used to be believed that asthma in children was inflammation in the lungs. Yet the theory believed by most physicians was that it "occassioned by a preternatural quantity of phlegm or mucus," said Rush. (2, page 4)

Upon dissecting children who died of the disease, Dr. Home discovered a large quantity of mucus in the trachea and bronchi.  "This opinion," Rush said, "is now pretty universally received by most practitioners, particularly in this part of the world."  (2, page 5)

However, based on his own experiences and observations as a physicians, he did not support this prevailing theory.  He said he witnessed many adults diagnosed with asthma or peripneumony in life who, when an autopsy was performed after death, they had not even the slightest sign of inflammation in the lungs and no evidence of respiratory disease.  (2, page 4)

A three-year-old child was seized with asthma early one morning, and his mother observed all the symptoms of hives: his breathing was difficult, his abdominal muscles were worked hard as he breathed, and pulse was rapid, his skin was warm to the touch and of livid color.  She was also concerned because he was coughing up quite a bit of blood.

So she called for Dr. Rush.

He traveled to the child's home by horse and buggy, and was met at the door by an anxious mother.  He followed her into the house, carrying his worn leather bag, without much as a word, and he saw a girl sitting on the edge of the couch.
Her chest was bare, and her ribs were evidently showing.  The shoulders of the girl were high, and his abdomen was vibrating hard with each inhalation.
Her skin was pale and dusky, and she had a bluish tinge around her lips and finger tips.  He observed all this in the first seconds of being in the same room as the girl.

"I'm sorry to be a bother," the lady wailed, "but I was so concerned for him breathing this way."

"You did right by calling me," he said to the lady to allay her anxiety.

He sat in a chair opposite the girl and set his bag between her legs.  He opened it and rummaged through its contents until he found a small box.  He opened it, exposing various small jars.  He took out one of them and opened the top.

"I need a teaspoon, please," he said nonchalantly.

She rushed into the kitchen and then back with a teaspoon that she handed the physician.  He handed her the bottle, and she poured some of the emetic onto the spoon and gave it to the boy.  Even though the Dr. knew it was of a horrible taste, the girl never winced; a sure sign she was desperate for any remedy.

The mother, who was wearing her pajamas and her hair was ruffled, grabbed a bowl from the shelf and gave it to the girl to use as an emesis basin.  The mother rubbed the girl's back and head as he emptied his stomach contents.  This initially seemed to ease his breathing, but, after twenty minutes of waiting, it seemed to be of no avail.

The doctor then took some small cups from his bag and a candle.  He lit the candle and warmed the cups.  He then had the girl lie on his back, and as he set the first cup upon the girl's chest the boy jumped up.  The mother hugged and consoled the girl, who was now crying vehemently.

"A bath," the doctor said, "A warm bath.  The steam might help."

The doctor sat next to the girl, and tried to sooth him with his words.  He actually thought he got a slight smile from the girl when he said something funny that had happened to him in the morning.  Perhaps, he though, the girl could at least forget his distress.

Right then his mother said, "It's ready."

The doctor helped the girl take off his pants, and carried him to the tub.  He gently set her in.  The boy immediately placed his arms on the side of the tub to lift his shoulders.  She was now struggling hard to breathe.  She was crying now, wailing.

Dr. Rush could feel the steam on his own face, and as he looked at the mother he could barely distinguish her tears from moisture from the steam.  After several moments of watching the girl suffer so, he lifted her from the water and set her back on the couch.  The girl was now unconscious.

The next day, after the funeral at the girl's home, Dr. Rush pulled the mother aside, once again, and gave her a big hug.  "I'm sorry I couldn't help," he said.

"It's okay," she whispered through tears.  "She's in a happy place now."

She introduced the doctor to her husband.  Dr. Rush then garnished the nerve to talk to them about something he had wanted to do for some time.

A few days later he sat in his study to finish working on his book about the disease he just tried to treat.  He wrote: "
As I was uncommonly anxious to see a dissection of a patient that died of this disorder, I prevailed, with some difficulty, with the parents to let me open her. By their particular desire, I called my worthy friend Dr. Duffield, to assist me in this dissection. Upon opening the thorax we found the lungs adhered pretty closely to the left side. this affection, we had reason to believe, was of long standing, from the closeness with which it adhered, and the force it required to separate it from the pleura. Those who are acquainted with the dissections of dead bodies, know that this is no uncommon thing in most of the bodies we meet with. There are few persons that have ever had an inflammation in their lungs or pleura, but what have adhesions of this kind, and yet feel not the least inconvenience from them. The lungs were quite found, nor could we perceive the least appearance of inflammation in them. Uon opening the Trachea, we found no signs of phlegm or hardened mucus in it. This, together with both the Bronchia, appeared in a sound and natural state.  this dissection, together with the arguments we advanced before, serve as irrefragable proofs that the disorder is not occasioned by the causes assigned by Dr. Home, but by some spasmodic affection of the lungs..  (2, pages 10-12)
By this autopsy he confirmed his suspicion that asthma was not inflammatory, and it was not caused by increased phlegm.   Instead, he suspected asthma "to be rather of the nervous or spasmotic," he wrote.  (2, page 7)

His listed the following as evidence:
  • "The suddenness with which children are seized with it.  This corresponds with other convulsive disorders we are acquainted with.  Did it depend upon the presence of phlegm in the wind-pipe, the disorder would come on more gradually; for the accumulation of this phlegm is certainly gradual."  (2, page 8)
  • "The disease in many cases is periodical.  This too corresponds with nervous diseases." It appears only at night, or at certain times of the day.  "If the disorder depended upon phlegm, it would certanly be more uniform in its effects, for we know that same causes will always (caeteris paribus)produce the same effects." (2, pages 8-9)
  • "We often see patients in this disorder relieved by nervous medicines.  The warm bath has sometimes given immediate relief, when they have appeared to be in the very jaws of death.  It seldom fails of affording a temporary relief.  Opium, we all know, is a powerful antispasmodic medicine. An ingenious physician in New-York, informed me, that he makes it a constant practice to give small quantities of thebaic tincture, joined with oxymel of squills, in the Hives, after giving a puke or two, and that he had seldom found it fail to succeed." (2, page 9-10)
  • The fact that the disease does not dissipate after the expectoration of phlegm is evidence that it is not caused by phlegm.   (2, page 10)
While he believed that asthma was spasmotic and nervous in both children and adults, that is where the similarities end.  He said:
Besides this, do we not perceive a considerable  resemblance between this disorder and the asthma in adults?  erhaps they difer from each other only in degree.  Now that asthma has always been supposed to be occasioned by a spasm upon the extremities of the Bronchia. (2, page 14)
(To view a case of adult asthma described by Dr. Rush, click here. It's only about four pages, and the words are big, so it should be a quick read.  Just remember that in many books printed in the 18th century many of the s's are replaced with f's, so this can make reading a little tricky, but not impossible.)

So, if you brought your child in to see Dr. Rush, and he diagnosed your child with asthma, what are the remedies that he might have used?  I will list them here:
  1. Bleeding: "Bleeding is generally ordered in the first stage of the disease.  It may act by taking off the tension and fullness from the vessels, which tend greatly to keep up the spasm. I am far, however, from thinking it of so much importance as some have imagined. The disorder, we have proved, is not of the inflammatory kind.  Bleeding therefore, in some cases, I believe, has done more harm than good."  (I just want to remind my readers here that inflammation in this era was considered congestion of blood in the vessels that could be remedied by removing some of this blood, hence the use of bleeding was often recommended. The procedure would be performed with the use of the lancet.  Pneumonia, apoplexy, rheumatism, and hydropsy are just a few examples of a disease considered to be caused by inflammation.) (2, pages 18-19)
  2. Vomits (emetics):  "Our chief dependence should be placed on these.  They may be given at all times of the disorder.  What vomits should we prefer?  It is a matter of little consequence which of them we use, provided we give them strong enough. the antimonial vomits are the surest, and most to be depended upon.  In the cases I have been called to, I have always given small doses of tartar emetic.  Some I know join calomel with vomits.  I cannot say I ever saw it do any service, and I believe few practitioners would venture to depend upon it alone.  Others join ipecacoana with the tartar emetic.  I cannot tell upon what this practice is founded." (2, pages 19-20)
  3. Warm bath:  "This w know is of singular use in all spasmodic disorders.  I have seen it in one or two cases afford immediate relief, and I have heard of several cases, in which it has saved the lives of patients, apparently in the agonies of death."  (2, page 21)
  4. Blisters:  "Blisters are justly ranked among the most powerful antispasmodics... It is a much better practice to apply the blisters directly to the breast, than between the shoulders." (2, page 21-22) 
  5. Bronchotomy (tracheostomy): While other physicians have performed the procedure in croup with some success, Dr. Rush did not recommend it.  (2, pages 24-25)
  6. Antispasmotics: Such as musk, camphor and opium may have an affect on the disease.  Dr. Rush said he used it a few times with success, although he had no evidence that it was a truly effective remedy for this disorder. (2, page 25-26)
  7. Other:  "Every attempt to lessen the number, or mitigate the violence, of diseases in children, is laudable, especially in a young country, like this, where the population is so much to be desired.   (2, page 26)
So Benjamin Rush was an essential figure in the creation of a new nation.  In a era when there were few physicians, Rush presented the residence of Pennsylvania with a solid option of obtaining medical advice and treatment.

And even thought the disease Dr. Rush described here is probably croup and not asthma, we can gather a good idea of how you would be treated by him if you requested his services to treat your asthma.

Note: In reviewing Dr. Rush's letter, I think it can be quite certain that the disease that Dr. Rush was describing here was not asthma, but croup. It makes sense that he would confuse the two diseases, as they often display similar symptoms. According to Alyn Brodsky, Hives was another way of describing a condition called Heaves, which was a description of the forceful act of children inflicted with this disease trying to inhale and exhale. (5, page 94)

  1. Good, Harry G., "Benjamin Rush and his services to American education," 1918, witness press
  2. Benjamin Rush,, accessed 1/3/14
  3. Rush, Banjamin, "A dissertation on the spasmotic asthma of children: in a letter to Dr. Millar, 1770, London, printed for T. Caddell, and D. Wilson and G. Nicoli, Eighteenth Century Collection Online Print Editions, originally published in October of 1769 in the Pennsylvania Journal.  According to It was one of the first medical publications published in the American colonies. 
  4. Rush, Benjamin, "An account of asthma, from an uncommon cause, Medical Observations and Inquiries, volume 5, London, as published in the book "Medical and philosophical commentaries,"1776, volume 4, pare 1, by a society in Edinburgh, London, pages 198-202, as 
  5. Brodsky,Alyn, "Benjamin Rush: Patriot and Physician," 2004, New York, St. Martin's Press
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