Friday, September 2, 2016

1830-1836: Kropp and Hirsch still think asthma is croup

We are now transported into the 1840s in our asthma history. Medicine has evolved so that physicians are now looking to improve knowledge of our disease. While many suspect it's a nervous and spasmotic disorder, others have their own theories.

In the year 1841 Dr. Charles J. B. Williams proves that bronchial muscles may spasm, and this is a revolutionary breakthrough for us.  While a few physicians continue to try to prove him wrong, most accept asthma is, after all, both nervous and spasmotic.

Ye there continues to be those who believe asthma is more than just a disorder of the lungs.  There continues to be physicians who believe any organic disease that causes dyspnea is indeed asthma, yet those physicians are becoming increasingly rare.

Dr. J. F. Kopp (Kropp) and Hirsch (Hirsh), both of Koeningsberg, Germany, are two such physicians who believe asthma is caused by swelling of the vocal cords and larynx. Perhaps because of their work, their fellow German physicains often referred to it as thymic asthma or Kopp's asthma.

According to an 1836 article in the London and Foreign Medical Review, Dr. Kopp read a paper at an anual meeting of scientific men in Koeningsberg that was republished in 1830. Dr. Hirsch then wrote a paper in 1835 basically confirming the findings of Dr. Kopp with some of his own cases studies. (7, page 237)

The disease, or symptoms as some referred to them, had various names, depending on who was describing them.  Some included: (1, page 207)(2, page 202)(3, page 2)(7, page 239)
  • Thymic asthma, or asthma thymicus (thymicum)
  • Kopp's asthma
  • Kopp's asthma thymicum
  • Millar's asthma
  • Hypertrophy (enlargement) of the thymus
  • Asthma infantum
  • Spasm of the glottis
  • Enlargement of the glottis
  • Croup
  • Crowing (crouplike inspiration of children)
  • Laryngismus stridulus anglorum (Harsh laryngitis)(1, page 207)(2, page 202)(3, page 2)(7, page 239)
Regardless of the name, the disease often results in "episodes of suffocation, during which respiration appears suspended, and which return periodically, especially on awakening or attempting to swallow, or when the child utters cries," according to an 1836 edition of the Dublin Journal of Medical Science. (4, page 514)

Andras said the German physicains usually referred to their "thymic asthma" as affecting mostly children between the ages of three weeks and eighteen months.  He said "it may last long, gradually augment in intensity, and prove fatal." (8, page 439)

An 1836 edition of the British and Foreign Medical Review summarized Dr. Kopp's description of an asthma attack as follows:
It is characterised by attacks of spasm of the chest and severe fits of suffocation. The breathing suddenly stops, or rather there is an extremely slight, piping, imperfect inspiration, forced, as it were, through the contracted glottis. The respiratory sound has some resemblance to the crowing inspiration of hooping-cough, but is much smaller and more acute; it is still more like the choking attempts at inspiration made during the hysteric spasm. In some cases, but rarely, there may be five or six piping or whistling inspirations, and then a few deeper and stronger. alternating with expirations so slight as scarcely to be perceived. In extreme attacks, the respiration stops entirely; the small inspiratory pipe then takes place, either in the beginning of the paroxysm or in its termination, being quite suppressed during the strength of the attack; and this symptom is pathognomic of the affection. The other symptoms are necessary consequences of the suppressed respiration; the body is extended forcibly backwards or the limbs drawn close up together; the face, which is fixed and expressive of great distress, is either purple or quite pale; the nostrils are expanded, the eyes fixed, the hands cold, the thumbs contracted, with involuntary dejections, &c. After a period of half a minute or a minute, occasionally even two or three minutes, the paroxysm ceases; the infant then cries for a short time, and immediately becomes cheerful and easy. When the constitution is very feeble, however, or the attack has been very severe, the child remains some time languid, pale, and sleepy. In the intervals of the paroxysms the child is quite well, without the slightest affection of the respiration. (7, pages 238-239)
The same article notes that death does occur at times.  It said:
On examination, besides the general appearances always following death from suffocation,—such as blueness of the skin, congestions of blood in the lungs and brain, &c,—the thymus gland is always found considerably enlarged. The degree of enlargement varies extremely, as does the natural size of the gland. At times it is enlarged chiefly in length and breadth, more commonly, however in thickness: in the last case the lungs are frequently thrust back by it into the posterior part of the chest; on other occasions, the gland is found closely connected with, and even surrounding, the large arteries and venous trunks of the thorax or neck." (7, page 239)
So what predisposes a person to an attack of this kind of asthma? The Medical Reveiw said Kopp beleived that "All diseases of the respiratory organs predispose to it,—such an catarrh, bronchitis, croup, hooping-cough, measles. Teething also predisposes to it." (7, page 239)

And the nature of the disease is as follows, again according to the Medical Reveiw:
It is an affection peculiar to early infancy, and consists of a periodical tonic spasm of the lungs, larynx, and glottis, perhaps also of the heart, eventually extending to the whole nervous system, under the form of epileptic convulsions. In it the thymus gland is more or less enlarged, but otherwise not diseased, and presses on the heart, bronchi, and large vascular trunks, impeding their functions. When, on examination after death, such an enlargement and abnormal compression exist, one need not seek further for proofs of the nature of the disease. (7, page 239)
Then the treatment is listed as follows: (7, page 240)
  1. In the attack nothing more can be done than to place the child in a proper position, to rub its spine, perhaps to dash cold water on it, &c.
  2. After the attack, to give antispasmodics, preparatory to the employment of means directed to the chief pathological state.
  3. To diminish and prevent the recurrence of all undue congestion and nervous excitement in the heart and lungs, by low diet, large and frequent local bleedings (every four or eight days,) blisters and issues on the chest, constant powerful purgatives, &c.
  4. To lessen the size of the thymus by anti-scrofulous, resolving medicines,— such as mercury, iodine, &c. (7, page 24)
William Stokes, in his 1837 book, described the exciting causes of Kopp's asthma. He said:
In this affection it is held, that any sudden emotion, causing a quick or forced inspiration, may bring on an attack of dyspnoea and suffocation, and even in some cases convulsions, so that in this way sudden death may supervene in a child, to all appearance perfectly healthy.
The Dublin Journal of Medical Science said the cause is "too great a development of the thymus gland."  Regarding the etiology (cause) of Kopp's asthma, Stokes said:
As yet the etiology of this disease is by no means established. and further researches are necessary to show how the condition of the thymus produces so remarkable an effect;—does it take an active part in these attacks, or is its permanent enlargement a passive cause for the injury? No data exist to answer these questions; but, from the similarity of cases of the crowing disease with those in which an enlarged thymus has been found, it seems probable that a morbid state of the thymus takes occasionally some part in causing the symptoms of Miller's asthma infantum. (2, page 202)
Dr. G. Lingen, in an 1839 article, said there were other physicians who supported this theory of asthma, but there were also those who did not.  He said:
English practitioners, however, as also the Germans Caspari and Pagenstecker, supposing that the hypertrophic state of the thymus is likely to be the effect and not the cause of this disease, contented themselves with assigning merely a symptomatic name for it, viz: Laryngismus stridulus, crowing or crouplike inspiration of children. But since Kopp and those practitioners who assisted him with their observations,  have vindicated the name of Asthma thymicum at least for those cases, which fell under their observation, and since other practitioners, equally creditable, have met with a disease resembling the one described by Kopp, without having found any anomalies of the thymus what ever; it is evident, that Kopp's Thymic Asthma and the Laryngismus stridulus Anglorum are diseases, apparently similar in their symptoms, but different as to their exciting causes. We say apparently similar, for it remains questionable whether the symptomatology of either of these diseases is completely known, so that, through further observations, a diognosis may yet be pointed out. (1, page 207)(see 7, page 240 for varoius arguments against Kopp's Asthma)
These diseases would not be further explored and diagnosed until they were once and for all removed from the rubric term asthma.  This is what would happen within the next few years, if the task wasn't already accomplished by some physicains.

Wolff Freudenthal, in a 1917 article in the New York Medical Journal, said the writings of Kopp and Hirsh represented the last hurrah for croup while still under the umbrella term asthma.  It would soon thereafter, thanks to the invention of the stethoscope and the discovery by Williams, be extricated from the rubric term asthma to become a disease entities of their own.

Freidenthal said:
They (Kopp and Hirsch) describe the now well known form of hypertrophy of the thymus, and the symptoms are clearly those of pressure on the trachea. There was no sign of asthma in the cases reported, but only dyspnea and the characteristic breathing of partial occlusion of the trachea. (3, pages 2-3)
A great many other varieties of dyspnea arising from various organic diseases had been previously described, and this so called thymic asthma of Kopp and Hirsch is the last one of its kind. At that time the difference between dyspnea and asthma was gradually being cleared up, and this was mostly due to the introduction of auscultation and percussion. (3, page 3)
So thanks to the discoveries of men like Williams, coupled with better methods of diagnosis, the nervous and spasmotic theories of asthma moved into the foreground, and croup was extricated from the rubric term asthma.

Note:  Despite an extensive search, I could find no further information regarding Kropp and Hirsch. 

Further reading: 
  • 1733-1805:  John Millar writes about asthma (4/23/15)
References:
  1. Lingen, G., "A Case of Asthma Thymicum Koppi, or Laryngismus Stridulus Anglorum, Crowing or Croup Like Inspiration," in the book "Miscallanies of Homeopathy," edited by an association of homeopathic physicians, 1839, Philadelphia, L. J. Kinderlen, pages 207-210
  2. Stokes, William, "A Treaties on the Diagnosis and Treatment of the Chest," 1837, Philadelphia, A. Waldie
  3. Freudenthal, Wolff, "Bronchial Asthma," New York Medical Journal: A Weekly Review of Medicine, edited by Edward Swift Dunster, James Bradbridge Hunter, Frank Pierce Foster, Charles Euchariste de Medicis Sajous, Gregory Stragnell, Henry J. Klaunberg, Félix Martí-Ibáñez, volume CV, January-June, 1917 (Saturday, January 6, 1917), New York, A.R. Elliot Publishing, Co., pages 1-5
  4. "Scientific Intelligence: Memoir on Thymic Asthma," , Dublin journal of medical sciencevolume IX, 1836, Dublin, published by Hodges and Smith, pages 514-522
  5. Montgomery, W.F., "Dr. Montgomery on the sudden death of children," London Medical Gazette, volume XVIII, Volume II for the sessions 1835-1836, 1836, London, printed for Longman, Rees, Brown, Green, and Longman, Paternoster Row, pages 828-833, reference to Kopp and Hirsch on page 833
  6. "Memoir of Thymic Asthma, compliled chiefly from the papers of Dr. Kopp and Hirsch of Koeningsberg," volume XVIII, Volume II for the sessions 1835-1836, 1836, London, printed for Longman, Rees, Brown, Green, and Longman, Paternoster Row, pages 843-847
  7. Hirsch, Dr., "Medicine: pathologica, practical and therapeutical: On Thymic Asthma: The British and Foreign Medical Review, Edited by John Forbes and John Conolly, Volume II,  April-October, 1836, 1836,  London, Sherwood, Gilbert and Piper, Paternoster Rowepages 237-240
  8. Andran, G., Dr., notes in the margins, "A treaties on Diseases of the Chest," by Rene Laennec, translated by John Forbes, 1838, New York, Philadelphia, Samual S. and William Wood, Thomas Cowperthwaite and Co.
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