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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