Friday, January 29, 2016

1700: Ramazzini's cure for occupational asthma

Once Ramazzini discovered that many his patients had occupational asthma, he studied the works of previous authors to discover the ideal remedy or cure.

He said:
Figure 1 --
Michael Ettmuller (1644-1668)
He was a German physician.

For asthmatic affections caused by metallic fumes, Etmuller, On respiratory ailments, suggests certain specific remedies and states that for this type of asthma the usual remedies have no effect. Accordingly, for this serious type he advises sweet mercury, turpeth mineral, cathartics, diaphoretic antimony, a bezoartic of gold, and the like. (1, page 29)
There were other remedies as well, depending on the hazards inhaled per the occupation.  For tinsmiths, Ramazzini said:
They should... be treated as though they were suffering from miner's asthma and should carefully avoid anything that is peculiarly drying.  Butter, milk, emulsions of almonds and of melon seeds, ptisan of barley, and the like will be beneficial. (1, page 61)
For those who inhale gypsum, he wrote:
Once gypsum has been taken into the body it does not yield easily to treatment, but various remedies were prescribed by ancient writers to correct the disorders contracted from it.  Galen, in Book II of his Antidotes, recommends a solution of the ashes of vine twigs. Guaineri approves, and prescribes the aforesaid ashes, a third of the dose by weight; Senert praises mouse dung. I have prescribed for workers of this class oil of sweet almonds freshly extracted, and emulsions of melon seeds, and these gave some relief." (1, pages 83-85)
Bakers and millers, who inhale the powders of flour, and of whom wearing a scarf over their mouth and nose is of little use, Ramazzini recommends:
To wash the face thoroughly with water, to rinse the throat very often with vinegar and water; to take oxymel and to purge themselves frequently in some way or other; when the breathing is oppressed, they should take an emetic so as to expel the sticky deposit from the passages.  I have seen men cured by an emetic, and some of them were almost at the last gasp. (1, page 227)
Ramazzini had reasonable expectations regarding the many individuals who were stricken with occupational illnesses, particularly "those workers (who) are liable to various diseases on account of the unwholesome nature of the materials that they mine, dig out, or handle and use in their workshops."  (1, page 87)

He understood that there was little means of protecting them other than changing occupations, which he reasonably expected not to happen.  So he continued to recommend coverings over the mouth and nose, even though he knew this was of little use.

Plaato (427-347 B.C.)
In regards to treating them, therefore, he references the Greek phlosopher Plato who records a discussion with Socrates regarding the desire of the god Asclepius and physicains to take care in treating commoners.

Ramazzini said Plato, through the words of Socrates, was one of the first to record the plight of hard working impoverished commoners, and the need for physician to cure them.  Ramazzini quotes Plato, who uses the voice of Socrates:
When a carpenter falls ill he expects his doctor to cure him by an emetic or purging or cauterising or a knife. But if he is ordered to begin a long course of dieting or to put compresses on his head or the like, he at once objects and says that he has no time to be ill and that it is not worth his while to drag out his life by sestoring, now to one now to the opposite treatment, and meanwhile neglects his craft. Then he says goodbye to the doctor, returns to his usual way of life, recovers and carries on his work, or if his body fails to bear up against the disease he dies and is rid of his troubles." (1, pages 87-9)(1)
Ramazzini then quotes Plato, through the words of Socrates again, describing the remedy.  (9, page 89)
For when a doctor has to treat men of this class his first duty is to restore them to health as quickly as possible by means of suitable and generous remedies.  Indeed, one often hears these poor wretches begging their doctors either to kill or cure them.  So when you treat the ailments of workers your chief care should be to give them remedies that work quickly and are ready to hand; otherwise they fret themselves to death from the weariness of prolonged illness and mental distress about the poverty and need of their families... Just so I have often observed in my practice that if working men do not get well quickly they go back to their workshops while still ailing and often evade the roundabout methods of the doctors.  (9, page 89)
This would be the mindset of the majority of the populace, or the working class, most of whom would find themselves poor, and most of whom would find themselves lame by their hard work by the age of 40 in many cases.

What they would not want, as noted by Plato and then Ramazzini, for the physician to take away his livelihood; his ability to do his work to support himself and his family.

Those who are rich, on the other hand, may have a unique perspective, as Ramazzini  (in paraphrasing Plato) explained: (9, page 89)
Of course in the case of the rich who have abundant leisure to be ill one may use that sort of treatment; they sometimes pretend to be ill just to show how well they can afford it... I mean men who pay doctors a trifling fee to sit by their bedside; but you must not treat busy workmen like that.   (9, page 89)
Ideally, it is thought from reading his observations, that Ramazzini would prefer to prescribe for such patients that they seek another line of work, although he understood, as did Plato before him, the reality of this prescription is that it will not come to fruition unless the patient finds himself completely lame and unable to return to work, or died.

As noted in the introduction of his translation of Ramazzini's book, Wright said:
In more than half the chapters, the chief risk to workers is the particles, usually 'sharp and acid', emitted from the materials handles and taken per os et nares -- a favorite phrase.  It is very dangerous for them to breathe, for every where is dust, animal, vegetable, ormineral; he would have welcomed a more effective gas-mask than the loose bladders and glass masks that had been more or less in use since the time of Pliny (23-79 A.D.).  But his real difficulty is that it is impossible to persuade workers, even when they are his patients, to take the simplest precautions.  In vain did he recommend personal cleanliness, the luxury of clean clothes on holidays, moderation in food, drink, and exercise, or warn them to avoid 'blocking the ores of the skin', when, scantily clothed, they left the overheated workshops for the chilly streets.  In several chapters occurs the phrase "with curses they repudiate their job", but they nearly all persist in it, in spite of his warnings that they should exchange it for one that better suits some peculiar physical condition; and some of them die with that curse on their lips.  His deep concern for the alleviation of the hardships suffered by the humblest workers is naturally not qualified by any reference to the interest of their employers, about whom he is silent; nor does he mention the possibility of unemployment." (1, xxvii)
After the publication of his book"De Morbis Artificum Diatriba," published in 1700 and 1714 Ramazzini was mocked by his peers for opposing common thought. His ideas were rejected.

He worked as professor of medicine at the University of Padua until he died at the age of 81 in 1714. (3) (4)

References:

  1. Ramazzini, Bernardino, writer,  "Disease of Workers," Wilmer Cave Wright, translator, 1964, New York, Hafner, page 243
  2. Ramazzini, ibid, pages 87-89; original quote by Plato from the following: Plato, "Republic," Book III.  A few passages later, Homer writes: "What profit would there be in his life if he were deprived of his occupation... but with the rich man this is otherwise, of him we do not say he has any specially appointed work which he must perform, if he would live.  He is generally supposed to have nothing to do.... if a man was not able to live in the ordinary way he (the god Asclepius) had no business to cure him; for such a cure would have been of no use either to himself, or to the State."  The Republic is a discussion between the Greek writer and philosopher Plato and his teacher, the Greek philosopher Socrates.http://hardluckasthma.blogspot.com/2012/07/120-200-ad-galen-wonders-what-causes.html
  3. "Bernardino Ramazzini Facts," biography.yourdictionary.com, http://biography.yourdictionary.com/bernardino-ramazzini, accessed 7/13/13
  4. "Bernardiino Ramazzini," EncyclopediaBritannica.com, http://www.britannica.com/EBchecked/topic/490551/Bernardino-Ramazzini, accessed 7/13/13
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Wednesday, January 27, 2016

1700: Ramazzini discovers occupational asthma

Ramazzine, from the title page of his book.
Most modern experts are impressed by Ramazzini's observations regarding occupational disease. Had his ideas been accepted, this would have greatly improved the quality of life for all those exposed to fumes, dusts and other such microscopic substances. 

However, as we observe many times in this history, sometimes new ideas are not generally accepted.  While the ideas of Ramazzini were duly noted by his peers, his ideas were not generally accepted by the medical community for another 250 years after the publication of his book.  

While modern experts marvel at the observations of Ramazzini, they have access to wisdom that Ramazzini did not have.

For instance, among the observations Ramazzini made during his survey of occupations was a high number of people who worked as sifters and millers who presented with dypsnea and cachectia. He diagnosed these men with asthma.

The modern expert knows that the true diagnosis of these men was probably not asthma but pneumoccociniosis, hypersensitivity pneumonitis, extrinsic allergic alveolitis, or farmer's lung

It's an inflammatory reaction caused by the repeated inhalation of particles small enough (less than 5 μm) to reach the lung parenchyma and evoke an immune response.

As Ramazzini recognized, chronic exposure can lead to respiratory disease, cor pulmonale, and an untimely death.

This was an impressive observation at such an early time in our history.  It's too bad his advice wasn't heeded by his peers.

Ramazinni cures occupational asthma

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1628: William Harvey discovers circulation, and proves it

Robert Hooke discovered the respiration
was not to keep the circulation of the
blood moving.In 1553 
While a book published by Andreas Vesaleas began a quest to learn about the human body, the discovery that the blood circulates by William Harvey would was a revolutionary breakthrough that allowed scientists and physicians to truly understand te human body, and how changes within caused disease.

Galen alluded to the idea that blood circulated through the body in the 2nd century. Yet in his many writings he described blood as moving back and forth between organs in a to and fro motion. Whether he had a notion it circulated is left to speculation.

Vesaleas was the first person to publish an accurate anatomy of the body. He performed autopsies, and had a painter paint what he saw, and this was published in a book, De humani corporis fabrica, in 1543. However, he erred in believing that the purpose of circulation was to cool the blood. (7, page 474)(11, page 243-4)

A contemporary of Vesaleas was Realdus Columbus (1516-1569).  He was a surgeon and professor of anatomy at Padua from 1544 until his death in 1569. He continued Servetus's work on circulation of the blood, describing the passage of blood from the vena-cave through the pulmonary circulation, and then through the left ventricle and aorta. (8, page 70-71)

Columbus also saw that blood changes in the lungs.  (11, page 243)

Andrea Cesalpino (1519-1603) was the first to describe the idea that blood circulates through the body.  But he usually doesn't get credit for this observation because he failed to prove it.

Hieronymus Fabricius (1537-1619) studied the venous system of the human body, and discovered membranous folds that he referred to as valves. He speculated that these allowed blood to flow upward. Since the blood pressure was lower the farther blood gets from the heart, these valves were necessary to prevent gravity from pulling blood on it's way back up the legs to the heart and lungs from being pulled back down to the lower legs and feet (and thus causing dropsy of the feet). (14, page 92)

In other words, his discovery of valves made Fabricus wonder if the blood circulated as opposed to moved in a to and fro motion as Galen had suggested. But whether this was true or not would be left to one of his students to determine, one of whom was William Harvey. (14, page 93)(15, page xxiii)

Michael Servetus discovered circulation to the publication of his 1553 book, although he also failed to prove it.  So the door was still wide open for a major breakthrough in science, and just the man to accomplish this task was William Harvey, who essentially took over the work of Servetus.

William Harvey (1578-1657)(11, page 242)
Medical Historian Thomas Bradford said Harvey was born in 1578 at Folkestone in Kent, and by the time he was ten-years-old he was accepted at Caius College, Cambridge, in 1593. He studied there for five years, then traveled to France and Germany, and then studied at the "celebrated" medical school at Padua. (14, page 119)

Bradford said that he studied under some of the most renowned anatomists of the era, including Dr. Fabricius. 14 page 91)(15, page xxiii)

Some say he lectured by candle light. Perhaps it was in this "light" that William Harvey was introduced to veins and valves. This wisdom, coupled with the enthusiasm of his instructor, inspired Henry to further investigate these veins and valves to learn more about them. "Perhaps," Harvey must have wondered, "Fabricius is right, that the blood does circulate." (14, page 119)

Bradford said he graduated from Padua in 1602 and began a practice in Cambridge in London.  Then, in he became a physician at Bartholomew's Hospital, and in 1615 became professor of anatomy and surgery at the college.  It was here he began his own anatomical research.  (14, page 119)

Like Andreas before him, he wasn't satisfied with the current method of just speculating about the movement of the blood and heart, or that assuming it was knowledge only God was privy to. He studied the heart and vessels in animals, and came to the conclusion that the heart was a pump, and it circulates the blood through the body. (9, page 168-169)

While his comrades initially rejected his theory that blood circulates through the body, Bradford said:
King Charles took great interest in these discoveries and witnessed several experiments. He appointed Harvey his physician in 1643.  In 1633 he accompanied the king and his court to Scotland.  When "Old Parr" died the king gave the body to Harvey to dissect.  (14, page 120)
Several years after he made this discovery, and when he was 50 years old, he would publish, in 1628, Exercitatio anatomica de Motu Cordis et Sanguinis (An Anatomical Exercise on the Motion of the Heart and Blood in Living Beings).  (14, (page 119-122)

Of course, once Harvey published his discovery in his 1628 book  his medical practice took a hit, and he was criticized by a dogmatic medical profession.  (11, page 246)(14, pages 119-120)(17)

However, in the end, Harvey would be proved right, and his ideas (of course based on science as opposed to theory) would win out, and he lived long enough to see his theory become accepted, said Garrison. (11, page 246) (also see 14, pages 119-120)

Perhaps it was due to his friendship with the king that his ideas were accepted before his death in 1657. (14, page 119-122)

Garrison said William Harvey "was the "greatest name in the seventeenth century... and whose work has exerted a profounder influence upon modern medicine than that of any other man save Vesalius.. it was the most momentous discovery since Galen's time." (11, )

Charles Auffray and Denis Noble, in a 2009 article in International Journal of Molecular Science, said that Harvey may even have come close to discovering how the heart may continue beating even after it is removed from the body.  They quote Harvey as saying:
The heart of an eel and of certain other fish and animals, having been taken out of the body, beats without auricles.  Furthermore, if yo ucut it in pieces, you will see the separate pieces each contract and relax, so that in them the very body of the heart beats and leaps after the auricles have ceased to move. (17)
Auffray and Noble said:
He (Harvey) could not, in his day, take this dissection further down to discover that the rhythmic mechanism was integrated at the level of individual cells, since the cell theory was formulated by Matthias Schleiden (1804-1881) and Theodor Schwann (1810-1882) two centuries later based on observations with the microscope introduced  in practice in the life sciences of Anton van Leeuwenhoek (1632-1723) only after Harvey's death.  However, he was the first to realise that rhythmicity was a property of the smallest structures he could discern. (17)
Had he had access to the microscope, perhaps Harvey would have made similar discoveries.  Yet he did not need to make any further discoveries, considering his discovery of circulation, and his proving it, was enough to secure his spot in history books.

Despite his accomplishments, Harvey's view that the purpose of breathing was to cool the blood "retarded the development of the true physiology of respiration for a long time." (11, page 242-244)

However, Garrison further explains that Harvey's proof that all blood passes through the lungs, and circulates around the body, made it possible for physiology to become a "dynamic science."  (11, pages 244-248)

It was through this discovery  that made it possible for later investigators to inject dyes and other solutions into the vessels that resulted in many anatomical discoveries, such as:  (11, pages 244-248)
  • Lacteal Vessels by Gasparo Aspelli in 1622
  • Thoracic Duct by Jean Pecquet 
  • The Pancreatic Duct by Georg Wirsung in 1642
  • Circle of Willis in by Thomas Willis in 1664
  • Capillaries in the lungs by Marcello Malpighi in 1661 (see below)
Of course each of these discoveries dispelled some ancient myth about the flow of substances through the body. For instance, Galen believed the purpose of "veins and lymphatics of the intestines carried chyle to the liver, said Garrison. This theory of Galen was disproved by the above discoveries, all thanks to the discovery that blood circulates through the body by Harvey. (11, page 246-7)

Galen believed the pulse would help determine changes in the pneuma, indicating disease. Harvey, on the other hand, described that the beating of the heart correlates with the pulse felt at the various points on the body. As the pulse is felt, this is when blood is forced through the many vessels of the body during contraction of the heart. The heart then relaxes, and this is when the heart receives blood. The strength and force of the pulse, therefore, is a direct correlation to the strength and force of the heart. (9, page 168-169)

He generally agreed with Columbus that the right ventricle of the heart pumps blood to the pulmonary arteries and then to the lungs where the blood is nourished, and the left side of the heart pumps blood to the various arteries of the body. As quoted by Osler: (9, page 170)
"I began to think whether there might not be A Movement, As It Were, In A Circle. Now this I afterwards found to be true; and I finally saw that the blood, forced by the action of the left ventricle into the arteries, was distributed to the body at large, and its several parts, in the same manner as it is sent through the lungs, impelled by the right ventricle into the pulmonary artery, and that it then passed through the veins and along the vena cava, and so round to the left ventricle in the manner already indicated." (10)
Marcello malpighi was the first to observe
capillary anastomosis, although he did not
attach importance to it.
Garrison added:
The most brilliant outcome of Harvey's experimental method was in the clearing up of the obscure matter of the physiology of respiration... Before Harvey's day, men still believed, with Galen (including Vesalius and Harvey), that the object of respiration was to cool the fiery heart, the purpose of the chest movements being to introduce air for generating vital spirits by the pulmonary vein, and to get rid of the heart's smoky vapors by the same channel. This Galenic notion was not a mere piece of symbolism, as in Richard Crashaw's (1612-1649) poem on St. Teresa (The Flaming Heart), but was part and parcel of actual belief about the physics of the circulation. "Before Harvey's time," says (Sir Clifford) Allbutt (1836-925), "respiration was regarded not as a means of combustion but of refrigeration. How man became such a fiery dragon was the puzzle." Harvey's demonstration showed that the blood is changed from venous to arterial in the lungs, but beyond that point, as even (Samuel) Pepys (1633-1703) has recorded in his Diary, no one could tell how or why we breathe (13, page 266)
Per Garrison, Pepy's wrote regarding respirations:
But what among other fine discourse pleased me most was Sir G. Ent about Respiration; that it is not till this day known or concluded among physicians, nor to be done either, how the action is managed by nature, or for what use it is." (13, page 266) 
While the Fabrica of Vesalias opened the eyes of the anatomist, the discovery that blood circulates inspired the anatomist to learn more about the physiology, or the functions of the body. In this way, he inspired people to learn more about medicine, and how medicine affects the various organs of the body. Harvey, therefore, is often referred to by many as the modern father of medicine.  (15, page xxiii)

References:
  1. Tissier
  2. Lagerkvist, Ulf, "The Enigma of Ferment," 2005, Singapore, World Scientific Publishing
  3. Potter, Elizabeth, "Gender and Boyle's Law of Gases," 2001, Indiana University Press
  4. Newman, William R, et al, "Alchemy Tried in the Fire," 2002, University of Chicago
  5. Lehrs, Ernst, "Man or Matter," 1958, Great Britain, Whistable Litho Ltd.
  6. Jindel, S.K., "Oxygen Therapy," 2008, pages 5-8
  7. Hill, Leonard, Benjamin Moore, Arthur Phillip Beddard, John James Rickard, etc., editors, "Recent Advances in Physiology and bio-chemistry," 1908, London, Edward Arnold
  8. Hamilton, William, "A History of Medicine, Surgery and Anatomy," 1831, Vol. I, London, New Burlington
  9. Osler, William Henry, "The evolution of Modern Medicine: A series of lectures delivered at Yale University on the Sillman Foundation in April, 1913," 1921, New Haven, Yale University Press
  10. Osler, ibid, pages 170, reference referring to William Harvey: Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus, Francofurti, 1628, G. Moreton's facsimile reprint and translation, Canterbury, 1894, p. 48. 20 Ibid., p. 49.
  11. Garrison, Fielding Hudson, "Introduction to the history of medicine," 1921, London, 
  12. Baker, Christopher, editor, "The Great Cultural Eras of the Western World: Absolutism and the Scientific Revolution 1600-1720: A biographical dictionary," 2002, CT, Greenwood Publishing; Herman Boerhavve published Biblia Naturae (Bible of Nature) in 1737, which was a two volume compilation of the works of Jan Swammerdam. Can you read Latin?
  13. Garrison, op cit, 266; (Samuel) Pepy's Diary, Mynors Bright's ed., London, 1900, v, 191
  14. Bradford, Thomas Lindsley, writer, Robert Ray Roth, editor, “Quiz questions on the history of medicine from the lectures of Thomas Lindley Bradford M.D.,” 1898, Philadelphia, Hohn Joseph McVey
  15. Brock, Arthur John, "Galen on the natural faculties," 1916, London, New York, William Heinemann, G.P. Putnam's Sons
  16. "History of Chemistry," historyworld.net, http://www.historyworld.net/wrldhis/PlainTextHistories.asp?ParagraphID=kpt, accessed 7/6/14
  17. Affray, Charles, Denis Noble, "Origins of Systems Biology in William Harvey's masterpiece on the Movement of the Heart and the Blood in Animals," April 17, 2009, International Journal of Molecular Sciences, 10(2), pages 1658-1669, found online at ncbi.nlm.hih.gov, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2680639/, accessed 7/8/14
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Monday, January 25, 2016

1700: Ramazzini describes occupational asthma

Figure 1 --
Bernardino Ramazzini (1613-1714)
Hippocrates was supposedly the first to write about a possible link between asthma and occupation.  Yet Bernardino Ramazzini was an Italian physician who defined occupational asthma as a common industrial lung disease.

Ramazzini was born in Carzi in 1633 and studied medicine at the University of Parma where he first became interested in occupational diseases.  He was the professor of practical medicine at the University of Moderna from 1682 to 1700 where he was appointed chair of theory of medicine.  It was during this time he extensively studied workers in various industries. He observed their working conditions, the symptoms they complained about, and he questioned them about their illnesses. (1)

Among his earlier investigations involved patients who developed sore, red, and burning eyes.  In an effort to help these patients, he  traveled to their workplace, which so happened to be among the sewage system.  By questioning workers, and investigating the workplace, he discovered a trend of severely red eyes among the workforce.  (4)(9, pages 95-107)

Perhaps it was this successful endeavor that set him off on a quest to investigate other occupations. He recognized that there were two types of diseases most prevalent among the occupations he studied, such as those associated with:

1.  "Certain violent and irregular motions and unnatural postures of the body." (9, page 5).

His work in this regard spotlighted a variety of occupations whereby the workers had diseases of their joints and bones. He therefore was the first to recognize the importance of good posture at work. (4)

2.  "Harmful character of the materials that they handle, for these emit noxious vapors and very fine particles inimical to human beings and induce particular diseases. (9, page 15)

His work in this regard spotlighted a variety of occupations whereby the workers had diseases of the eyes, mouth, nose, lungs, and other internal organs as a result of inhalation of fumes, gases, and dust at work. He therefore was the first to recognize the importance of good ventilation at work. (in 1743 Dr. Stephen Hales invented "The first mechanical ventilator")

In 1700, the same year he was appointed professor at the University of Moderna, the results of his observations were published as De Morbis Artificum Diatriba (Diseases of Workers), and then subsequently discussed among the medical community. (2)

Although, as J.S. Felton explains, it was not until the English translation of the Latin version of the book in 1940 by Wilmer Cave Wright that his works became "widely known." (2)

Of this, Felton said:
"Familiarization with the new English version led to multiple references to the wisdom of Ramazzini, probably the most frequently cited aphorism being an addition to the counsel of Hippocrates to physicians regarding the initial visit to a patient: 'When you come to a patient's house, you should ask him what sort of pain he has, what caused them, how many days he has been ill, whether the bowels are working and what sort of food he eats.' Following this citation, Ramazzini writes, 'I may venture to add one more question: What occupation does he follow?" (2)(9, page 15)
Wright's translation of "Diseases of Workers" was an easy read, and by reading it one should quickly garnish respect for the amplitude of work that went into his study of diseases of the workplace.  In his preface, Ramazzini explains: 
 "For we must admit that the workers in certain arts and crafts sometimes derive from them grave injuries, so that where they hoped for a subsistence that would prolong their lives and feed their families, they are too often repaid with the most dangerous diseases and finally, uttering curses on the profession to which they had devoted themselves, they desert their post among the living.  While I was engaged in the practice of medicine, I observed that this very often happens, and so I have tried my utmost to compose a special treatise on the diseases of workers." (9, page 7)
The first chapter of his book is dedicated to those most likely to develop high rates of mortality and morbidity due to their occupation, and this would include those working in poorly ventilated areas, such as would be the case for miners of gold, silver, copper, silver, etc. They, for example, and according to Ramazzini, inhale the dust, powder and fumes created deep under the earth, increasing their chances of developing...
Figure 2 --
Claudius Galen (129-200 A.D)



"...dyspnoea, phthisis, apoplexy, paralysis, cachexy, swollen feet, loss of teeth, ulcerated gums, pains in the joints, and palsy. Hence, the lungs and brain of that class of workers are badly affected, the lungs especially, since they take in which the air mineral spirits and are the first to be keenly aware of the injury. Presently, when those vapors have gained entrance to the dwelling-house of life and are mixed with the blood, they pervert and pollute the natural composition of the nervous fluid, and the result is palsy, torpor, and the maladies above mentioned. Hence, the mortality of those who dig minerals in mines is very great, and women who marry men of this sort marry again and again." (9, page 18)
Figure 3 --
Georg Wolffgang Wedel (1656-1721)
He was a German professor of
medicine and alchemy.
Such workers, especially those who mine or work with mercury, are also at high risk for developing asthma.  Ramazzini explains that he was not the first to recognize this.  He said Hippocrates described it, and he said Galen once told a story about how he entered the mine and observed the workers.  Ramazzini said:
Galen, in properties of simple medicaments, describes a cave that he saw was in Cyprus from which water was being carried out by the workmen for making green vitriol, and he says that he went down into a depth of about one-eighth of a mile and observed drops of green water dripping into a pool and was keenly aware of a suffocating and almost intolerable odor. He adds that he saw that the workmen, who were naked, carried out the water with utmost haste and ran back quickly; nothing, in fact, is worse for the lungs than acid of whatever kind, and vitriol there is a great deal of acid."
Figure 4 --
Daniel Sennert (1572-1637)
He was professor of medicine
at the University of Wittenberg,
and author of books on alchemy.
While ancient authors mentioned the harms caused by poisonous gases in mines, Ramazzini also gives credit to other authors.  Ramazzini said:
(Jean Baptist van) Helmont in his treaties On asthma and cough describes a kind of asthma which he classifies as something between dry and humid asthma and says that miners and refiners of metals, minters, and other such workers are liable to that asthma because of the 'metalic gas' that they inhale, which is so powerful that the vessels of the lungs are obstructed. Wedel (figure 3) in his Pathologia medica dogmatica (1692) speaks of 'miner's asthma' and says that workers in mines are liable to this ailment; he also says that Stockhausen published a whole treaties on this kind of asthma wherin he ascribed the cause of the malady to mercury of lead; for much mercury is present in lead and makes it heavy.  The same author explains how those metallic fumes bring about the cruel monster 'miner's asthma' by drying up the bronchia, but this is also caused, he thinks, by their being blocked by sooty smoke. Sennert (figure 4) in his work On the agreement and disagreement of chemists and Galenists (1619) relates that a doctor whose practice was at the metal mines of Meissen told him that in the corpses of miners had been found the metals that in life they had toiled to dig.  Statius (figure 5) in his invitation to Maximus Junius (Vibius) who was then living in Dalmatian Mountains, wittily describes that company of men doomed to Acheron who come up from the mines, as he says: "Pale from the sight of Dis (Pluto) and yellow as the gold unearthed." (9, pages 22-23)
Figure 5 --
Publius Papinius Statius (45-96 A.D.)
He was a Greek Poet.
So physicians observed long before Ramazzini the undesirable affects of inhaling fumes, dusts and powders from deep underground.

Ramazzini said efforts were sometimes made to protect workers, such as noted in the following passage:
In order to purify that imprisoned air infected by the exhalation emitted from the minerals and the bodies of the miners, also by the fumes of lighted lamps, superintendents of mines regularly expel the thick stale air and force in fresh and purer air by means of certain ventilating machines which they connect by shafts with the bottom of the mine...  It is evident that the ancients also paid great attention to the safety of miners, for, according to Julius Pollus (Emperor Commodius appointed him chair of rhetoric in the 2nd century), they used to cover their heads with sacks.  Over their faces they did loose bladders so that they could see through them without inhaling the pernicious dust; Pliny (the elder) says that this is done by polishers of inium.  Nowadays, especially in arsenic mines, they wear glass masks, a safer and neater device mentioned by (Athanasius) Kircher (in The subterranean world)(1665)." (9,page 27-8)
Athanasius Kircher (1601-1680)
He was a German author of 40 books
some of which were on medicine.
The inhalation of minerals, and the diseases caused thereby, are in no way, according to Ramazzini, limited to miners, as any person whose occupation involves working with minerals is at risk of disease, including all those who... (9, page 15)
"...shovel, smelt, cast, and refine the material that has been mined.  They are liable to the same diseases, though in less acute form, because they perform their tasks in the open air.  However, in the course of time the metallic fumes that they breathe make them short winded, splenetic (depressed), lethargic (tired), and in the end they pass into the class of consumptives (appearing to waste away)."  (9, page 31).
This class likewise includes "goldsmiths, alchemists, distillers of aqua fortis, potters, mirror makers, founders, tinsmiths, painters, and others." (9, page 15)

It also includes people who lived in areas around mines, or those who work or live near where such work is done.

So, as you can see, his book was, as noted by the authors of britannica.com...
the first comprehensive work on occupational diseases, outlining the health hazards of irritating chemicals, dust, metals, and other abrasive agents encountered by workers (6).
The book went through two editions.  The first, published in 1700, was a compilation of 42 "groups of workers."  The second, published a year before his death in 1713, was an enlarged version that included 12 more "groups of workers."  (11, page vii)

The following are the common occupations, or "groups of workers," he discovered to be linked to asthma and other pulmonary and similar disorders:
  • Miners: Inhalation fine particles of dust, powders and fumes of minerals in non-ventilated areas deep under the earth; they are closest to these elements, and are most likely to suffer the direst consequences, including asthma and other respiratory ailments. (9, pages 15, 21)
  • Gilders: They adorn objects with metals like gold to make them more beautiful. They inhale the fumes of the burned off metals, such as mercury, which is harmful to the entire body, especially the lungs and brain. (9, page 33)
  • Tinsmiths: Inhaling fumes while making such lightweight objects such as milk pails, basins, cake pans, bells, swords, etc. When it is heated, fumes of mercury are also inhaled, and this ultimately leads to respiratory complications, such as asthma. (9, page 59, 61)
  • Glass workers and mirror makers:  Caused by standing "continually half-naked in freezing winter weather near very hot furnaces... and at the day's end when work is over they must pass from that fiery workshop to colder places. Now no constitution however strong and robust can long endure such violent and sudden changes of temperature.  Pleurisy, asthma, and a chronic cough are the natural result... those who make mirrors become palsied and asthmatic from handling mercury." (9, page 63,65)
  • Gypsum and lime workers: They build columns for buildings and other structures of lime and gypsum, thereby inhaling the fumes and dust. He notes that "I have observed that those who persist in this kind of work nearly always die asthmatic and cachectic." (9, page 85)
  • Tanners: They inhaled fumes of decaying carcasses and chemicals used to tan hides, such as in the preparation of materials like leather, strings of musical instruments, etc. (9, page 131, 132)
  • Bakers: Inhalation of wheat, rye, and flour dust.  "Those who separate the flour from the bran with sieves or shake and turn over sacks, however they may protect their faces, cannot help taking in floating particles of flour with the air they breathe; these ferment in the salivary juice and stuff up not only the throat but the stomach and lungs too with a sort of paste, which makes them very liable to coughs, short of breath, hoarse, and finally asthmatic, because the trachea and pulmonary passages become lined with this crust and it hinders the free circulation of air." They also have a tendency to ailments such as colds and pneumonia due to working in places "kept very warm (as in winter)... and then going out into the cold air where "pores of the skin are seriously constricted."(9, pages 226, 227)
  • Millers: They develop asthma due to the inhalation of grain dust. "They must be continually whitened by the floating particles of flour; the grain is ground into the finest powder and the flying particles fill the mill-house, so that, willy nilly, the mouth, nostrils, eyes, and ears, in fact every part of the body is besprinkled with flour.  I have known many to become asthmatic from this cause and finally to lapse into dropsy."  (9, page 231)  Many credit this passage as the first description of baker's asthma. 
  • Grain sifters:  Fine particles of dust from wheat, similar grains, volatile salts, and "the residual dust and decay caused by the grubs, borers, and wevils (a beetle) that consume the grain and by other such corn pests and their excrements" in granaries and barns are inhaled.  "The pulmonary passages become coated with crust formed by dust, and the result is a dry and obstinate cough... and almost all who make a living by sifting or measuring grain are short of breath and cachectic and rarely reach old age; in fact they are very liable to lapse into orthopnoea and finally dropsy."  (9, pages, 243, 249)
  • Stone cutters (sculptors, quarrymen, etc): "When they hew and cut marble underground or chisel it to make statues and other objects, they often breathe in the rough, sharp, jagged splinters that glance off; hence they are usually troubled with a cough, and some of them contract asthmatic affections and become consumptive." Sand is sometimes found in their lungs, so the best remedy is "to to be as careful as possible not to breathe in those minute fragments by the mouth." (9, pages 249, 251, 253)
  • Carders: Those who comb and clean fibers of wool or silk before spinning, and particularly those who card flax and hemp, are exposed to "foul and poisonous  dust" that "flies out of these materials, enters the mouth, then the throat and lungs, makes the workmen cough incessantly, and by degrees brings on asthmatic troubles." Men who make silk rolls of silkworms, or otherwise comb them into fine threads, often die as consumptives, living short lives. (9, pages 257, 259)
  • Ragmen: A person who collects and sells rags that have been "wetted through with urine many a time and otherwise polluted, and in shaking and combing it they take in by the mouth a great deal of foul dust."  Others, such as the Jews, collect old rags to sell to paper makers.  In the process of stuffing them "into great sacks... there comes from it a wonderful and horrible stench, almost beyond belief.  From this sort of work they contract coughs, asthma, nausea, and vertigo."  (9, page 291)
  • Runners: Moderate running is fine, but "when one runs very fast the vesicle so the lungs are overinflated, and the blood flowing back through the... heart is checked in its course... so that it cannot flow freely into the vessels of the lungs; hence of necessity it stagnates in the head and provokes serious diseases" such as hernia and asthma.  They are also at risk for pneumonia due to exposure to the "wind and rain and clad in garments that furnish little protection; they are drenched with sweat, then chilled through, and thus the pores of the skin are stopped up, so that they cannot but be attacked by fatal diseases, especially of the respiratory organs which in running work hardest and become overheated. "This is why, nowadays, when runners have reached the age of forty, they are retired as unfit for this service and dismissed to public life."    ( (9, page 295)
  • Horseback Riders: Anyone who grooms (breaks or trains) or rides horses is likely to develop asthma for many of the same reason that runners develop asthma.   (9, page 303)
  • Porters:  They are likely to develop asthma due to the strain they put on their bodies from "loading and unloading merchandise from the cargo-ships...When a porter is in the act of hoisting a load on to his shoulders, he takes a deep breath, but from then on he breathes out very little; hence the pulmonary vesicles are far to much inflated, so that the vessels of the lungs that transmit and receive the blood cannot, owing to the pressure, perform their function properly; so it is no wonder that the blood vessels are easily ruptured from excessive distension... from the same cause, when the tonus of the thoracic muscles breaks down and the texture of the lungs becomes flaccid, porters soon become asthmatic..."  (9, page 311)
  • Farmers:  Mainly due to exposure to "the inclemency of the weather." They are at high risk of pleurisy, pneumonia, and asthma. Due to such exposure, "the whole mass of humors is excited to a febrile effervescence, and thus in the vessels of the lungs into which flows all the venous blood, thick and viscid humors readily stagnate.  This is why, as I have often noticed, whenever an epidemical constitution of lung disease begins to assault us, it gives the signal to attack first the country-people and completely dominates them." (9, page 337)
  • Professors/ Orators: They develop asthma because "all through the winter and spring they lecture from their platforms till they are hoarse, trying to instruct young students, and at the end of the season they demonstrate by their uneasy and asthmatic condition what serious ailments of the chest can be caused by such a strain on the voice; this applies to all whose occupation obliges them to overwork the voice. (9, page 389)
  • Athletes:
    Titus Maccius Plautus (254-14 B.C.)
    Ramazzini said he became exhausted and dyspneic
    after running too fast. Galen, Celsus, and Paul of Aegina,
    and Settalla and Guastavini, as well as others,
    also mentioned exercise induced injuries. 
    Vessels become congested, causing hernias, the often burst,
    causing pulmonary hemorrhage (spitting up blood)
    or hemorrhage of other parts of the internal body.
    Celsus advised runners with kidney trouble not to run.
    (9, pages 295-299)
    They are susceptible to apoplexy, cardiac syncope, suffocative catarrh, rupture of the vessels of the chest, and other causes of sudden death (probably even asthma).  "The principle cause of these maladies was excessive plethora (large amount) of the humors and distension of the blood vessels so that the circulation of the blood was either excessively retarded or altogether inhibited; there ensued in the veins 'interceptions' to use the Hippocratic term, i.e. stagnation of the blood and stoppge of all the fluids so that sudden death was the inevitable consequence." (9, page 319)  Due to linking athletics, running, and horseback riders to certain ailments Ramazzini is often considered the father of sports medicine.
  • Alchemists: From the inhalation of fumes they often become "palsied, blear-eyed, toothless, short of breath, and disgusting... for they must stand by and observe the whole process, enduring the test of fire and the fumes of coal, if their medicaments are to be properly prepared and prescribed with safety."
  • Potters: People who make pottery are exposed to the fumes of metals, particularly of "roasted or calcined lead for glazing their pots... their mouths,nostrils, and the whole body take in the lead poison that has been melted and dissolved in water; hence they are soon attacked by grievous maladies."  They become paralytic, splenetic (depressed), lethargic (tired), cachectic (thinned), toothless, and pthisical (wasting). 
  • Tobacco workers: "Those who make tobacco, breathe freely those bad odors and the flying particles of dust which when very fine are correspondingly sharp, so that they prick and dry up the delicate coats of the lungs and trachea." (9, page 143)
  • Painters: They develop asthma, chachexia, and melancholy from "the materials of the colors that they handle and smell constantly, such as red lead, cinnabar (a product of mercury), white lead, varnish, nut-oil and linsed oil which they use for mixing colors; and the numerous pigments made of various mineral substances." Painters make their paints using various metals because this makes them last longer, although they are also forced to inhale their fumes.  (9, age 67, 69)
  • Well diggers:  They are at risk of diseases of the chest, catarrh and cachexia because "every day they are hauled up drenched with sweat, partly from the digging, partly from the heat that settles in the well." (9, page 457)
  • Copper Smiths: They develop severe affections of the lungs (asthma?), for while they beat the copper with hammers, poisonous emanations arise from the hammered  copper and by the mouth enter the stomach and lungs, as they themselves admit." (9, page 437)
  • Printers:  They are susceptible to "pleurisy, pneumonia, and other diseases of the chest; for in winter they have to spend the whole day in rooms that are carefully shut up and as hot as an oven, if they are to do the work properly and dry the printed sheets.  When, later, they go from these warm rooms into the cold outer air they are very apt to incur constriction of the pores of the skin and perspiration is suddenly checked; hence ensue the ailments mentioned above." (9, page 419)
Ramazzini was a physician whose ideas were ahead of his time, or about 250 years ahead of his time.  Had his ideas been accepted, this would have probably prevented much morbidity and mortality, perhaps improving the quality of life, and the longevity of life, for workers exposed occupational hazards.  

 References: 

  1. Franco, Giuliano, Francesca Franco, "Bernardino Ramazzini: The Father of Occupational Medicine," American  Journal of Public Health, September, 2001, 91(9), page 1382
  2. Felton, J.S., "The Heritage of Bernardino Ramazzini," Occupational Medicine, 1997, volume 47, number 3, pages 167-179
  3. Navarra, "Encyclopedia of Asthma and Respiratory Disorders," 2003, New York, 
  4. "Bernardino Ramazzini Facts," biography.yourdictionary.com, http://biography.yourdictionary.com/bernardino-ramazzini, accessed 7/13/13
  5. Bernstein, David, editor "Asthma in the workforce," 1999, 2nd edition, New York, Marcel Dekker Inc. 
  6. "Bernardiino Ramazzini," EncyclopediaBritannica.com, http://www.britannica.com/EBchecked/topic/490551/Bernardino-Ramazzini, accessed 7/13/13
  7. Hirschmann, Jan V., Sudhaker N.J. Pipavath, J. David Godwin, "Hypersensitivity Pneumonitis: A Historical, Clinical, and Radiologic Review," Radiographics, radiographics.rsna.org, November, 2009, Volume 29, Number 7, pages 1921-1938
  8. Jackson, Mark, "Asthma: A Biography," 2009, New York, Oxford University Press, page 67
  9. Ramazzini, Bernardino, writer,  "Disease of Workers," Wilmer Cave Wright, translator, 1964, New York, Hafner, page 243
  10. Ramazzini, op cit, pages 87-89; original quote by Plato from the following: Plato, "Republic," Book III.  A few passages later, Homer writes: "What profit would there be in his life if he were deprived of his occupation... but with the rich man this is otherwise, of him we do not say he has any specially appointed work which he must perform, if he would live.  He is generally supposed to have nothing to do.... if a man was not able to live in the ordinary way he (the god Asclepius) had no business to cure him; for such a cure would have been of no use either to himself, or to the State."  The Republic is a discussion between the Greek writer and philosopher Plato and his teacher, the Greek philosopher Socrates.http://hardluckasthma.blogspot.com/2012/07/120-200-ad-galen-wonders-what-causes.html
  11. Rosen, George, introduction to the 1964 reprint of Ramazzini's work "Diseases of workers," translated by Wilmer Cave Wright, pages v-ix
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Friday, January 22, 2016

1699: Asthma still considered a symptom

While Jan Baptiste van Helmont was probably the first physician to refer to asthma as nervous, Thomas Willis was usually credited with forming the nervous theory of asthma. Regardless, most physicians considered asthma as nothing more than a symptom of some other malady.

Of this, Wolff Freudenthal, in his 1917 article in the New York Medical Journal titled "Bronchial Asthma," said most physicians of the 17th century referred to asthma in the following manner:
Neque cnim asthma, anhelatio ipsa morbus est, sed morbi symptoma.
When run through Google Translate we get:
Nor could it asthma, panting is a disease itself, but of the disease symptoms. Nor could it asthma, panting is a disease itself, but of the disease symptoms.
Of this, Freudenthal said:
These words—repeated so very often in our times—gave evidence that the physicians in those days considered asthma only as a symptom, nothing being heard of a nervous or spasmodic asthma. 
So this is yet more evidence of how slowly knowledge of asthma was accepted by the medical profession.

References:
  1. 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
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Wednesday, January 20, 2016

1600-1800: Physicians study pneumonia

After Hippocrates defined pneumonia in 400 B.C., little more was learned about this disease and its treatment.  The same was true of the Middle Ages, where the only discussion about it was by physicians living among the Eastern world.

Maimonides, a Jew living among Arabs, was a physician whose medical ideas were greatly appreciated.  He mentioned pneumonia, and said:
The basic symptoms which occur in pneumonia and which are never lacking are as  follows:  acute fever, sticking (pleuritic) pain in the side, short rapid breaths, serrated pulse and cough."
This was the most accurate description of the disease up to this time, and the first to be remotely similar to the modern description of the disease.

Scottish physician and asthmatic William Cullen described pneumonia as either inflammation of the "viscera of the thorax or the membrane lining that cavity." (2, page 3)

 In 1792, Dr. Jean P. Frank mentioned that pneumonia "must be studied under the common name pleuro-pneumonia."(2, page 3)

While one cannot deny that historic accounts and descriptions of epidemics were accurate, the descriptions of the way people died were often eerily similar to what doctors of today would diagnose as pneumonia.    

So while people suffering from the Black Plague, for example, may actually have been infested and diagnosed with the plague, many may have had their immune systems so wiped out that it was easy for pneumonia to set in.  (2, page 4-5)

This may explain monk descriptions as cough, bloody spitting, diarrhea and vomiting and fever, catarrh, difficulty breathing, pain in the side, weakness, delirium and quite often death. (2, page 4-5)

Pneumonia symptoms were also described during influenza outbreaks, which suggest that the flu weakened the immune response to the point where pneumonia set it.

Such an outbreak occurred in 1762, 1775, 1782 and again in 1837.

The death of the garrison of Philisbourg, in 1688,  was attributed to exposure to a "cold north wind... and camp life." (2, page 6)

Bleeding continued to be a common treatment for pneumonia.  Autopsies results on the garrison of Philsbourg ,and others afflicted with the disease,  described the lungs as "actively inflamed and hepatised, and in many parts purulent, the chest and pericardium filled with bloody serum and polypi in the right auricle of the heart." (2, page 6)

Hermann Boerhaave  published Aphorisms in 1709 and described that lobar pneumonia should be recognized as a separate disease from other infections of the lungs.  (6, page 3)

Giovanni Battista Morgagni recognized that pneumonia caused a solidification in a lobe of the lungs and referred to it as lobar pneumonia. (8, page 193)

John Huxham (1692-1768)
John Huxham, an English physician who wrote an "Essay on Fevers" in 1755, studied the writings of Hippocrates, Celsus and Aureatus, and, based on his own observations of diseases, came up with remedies for the various medical conditions.

One thing of significance regarding Huxham is he was in ardent opposition to what he referred to as quack medical therapy.

For the treatment of pneumonia he developed a procedure called the "Huxham tincture."  It was a medicinal drink that was recommended by physicians for many years.

Matthew Ballie spent quality time performing post mortem studies, and he described many diseases of the lungs.  In 1793 he described the inflamed parts of the lungs (pneumonia) as being covered by a solid mass similar to a liver, and he referred to it as "hepatisation."  (8, page 193)

So we can see that, even heading into the 19th century, little changes had occurred regarding the description and treatment for pneumonia.

References:
  1. "Leading Cause of Death, 1900-1998," http://www.cdc.gov/nchs/data/dvs/lead1900_98.pdf
  2. Sturges, Octavius, "The Natural History and Relations of Pneumonia," London, 1876
  3. "History of Pneumonia," The British Medical Journal,  Jan. 19, 1952, pages 156-158
  4. Schmitt, Steven K., "Oral Therapy for Pneumonia:  Who, When, and With What?" editorial, Journal of Clinical Outcomes Management,  March, 1999, vol 6, No 3, pages 48-50
  5. Bellis, Mary, "The History of Penicillin," http://inventors.about.com/od/pstartinventions/a/Penicillin.htm
  6. Marrie, Thomas J, "Community Acquired Pneumonia," 2001, New York, chapter one by Jock Murray, "The Captain of Men and Death: The History of Pneumonia."
  7. Auld, A.G., "The Pathological Histology of Bronchial Affections," The Lancet, Aug. 6, 1892, page 312
  8. Allbutt, Clifford, ed, A System of Medicine, 1909, Toronto, chapter on "Lobar Pneumonia,"  by P.H. Pye-Smith, pages 191-205
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1679: The term emphysema is coined

Theophile Bonet (1620-1689)
The 42-year-old Alaskan woman sat by the crackling fire 1,600 years before the birth of Christ.  She was severely winded after just a short walk with the children. Her chest heaved up and down, occasionally interrupted by a dry, hacking, painful cough.

"I can no longer do  this," she decided, working hard to stop the tears.  The children stood around her silent and concerned.  These episodes were happening more frequently now, so often that she could barely stand it.  "I'm fine," she said.  It was a lie.

Looking into our prism we can see the woman obviously suffered from Cronic Obstructive Pulmonary Disease (COPD), although back then the disease she suffered from was poorly understood. In Alaska there may have been no treatment at all other than rest.

We know she probably acquired the disease gradually over time as she continued to inhale smoke from the same fires she used to cook food for the children and their parents.  We know she probably died slowly from lack of oxygen.

Nearly 1,600 years later, a Greek physician named Hippocrates described asthma for the medical community, describing it as dyspnea, or shortness of breath.  He was not aware of different causes of dyspnea, so they were all included under his umbrella term asthma.

Yet somewhere, tucked nicely under this umbrella, were patients who had inhaled some microscopic substances, perhaps a chemical, that caused changes of some airway tissue and destruction of others.  The end result were diseases we now refer to as chronic bronchitis and emphysema, and that we lump under the umbrella term chronic obstructive pulmonary disease.

It would be another 2,000 years before emphysema would be described around 1650 A.D.  The 17th century was well known as a time when physicians were performing autopsies in order to match symptoms observed in life with changes that occurred within the body.

Emphysema became a term that would be used to describe lungs that were larger than normal due to the fact they held abnormal amounts of air.  The term would come from the Greek term physe, which means "to blow into."  They did not, however, understand why the lungs had extra air blown into them, so this resulted in much speculation.

So it was in the year 1679  that a Swiss physician named Theophile Bonet performed over 3,000 autopsies on patients he followed, and was among the first to describe emphysema as a medical condition of "voluminous lungs" in his book Sepulchretum. (2) (3) (4)

Giovanni Morgagni (1682-1771) wrote how he respected the works of Bonet, and he himself described 19 cases of "turgid" lungs in his classic work "On the seats and causes of disease." (3)

About 200 years after the death of Morgagni, the mummy of a 1,600 year old woman was discovered in Alaska. The woman was found to have evidence of emphysema, and this may be the oldest reported case of COPD.  (1, page 85).

References:
  1. Qutayba Hamid, Joanne Shannon, James Martin, "Physiologic Basis of Respiratory Disease," 2005, Montreal, page 85-99
  2. Bhatia, K. Sujata, "Biomaterials for Clinical Application," 2010, London, page 100
  3. Petty, Thomas L, "The History of COPD,"Int. J. Chron. Obstruct. Pulmon. Dis., 2006, March; 1(1): 3-14
  4. Crellin, J. M.D., "Selected Items from the history of pathology," Am J Pathol. 1980 January; 98(1): 212.
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Monday, January 18, 2016

1672: Vieussens discovers difference between asthma and cardiac asthma

Raymond Vieussens (1635-1715)
Once William Harvey proved blood circulates in 1628, this opened the door for investigators to study the heart, circulation of the blood, and related diseases. Such studies lead to a man named Raymond Vieussens breaking the paradigm that all dyapnea should be classified under the umbrella term asthma.

Vieussens performed a bunch of autopsies, with the specific intent of studying the heart and the circulation of the blood.  Between the years of 1672 and 1676 he came to the conclusion that sometimes dyspnea is caused by heart disease, and such cases of dyspnea should be classified as cardiac asthma, as opposed to pure asthma, explains Fielding Hudson Garrison in his "Introduction to the history of medicine."  Garrison wrote the following about Vieussens:
Vieussens first correctly described the structure of the left ventricle, the course of the coronary vessels*, the valve in the large coronary vein, and the centrum ovale in the brain. In his many autopsies he noted the significance ofpericardial adhesions and the relation of heart disease to asthma and hydrothorax (1672-6)... giving the character of the pulse and the pathological features.
Robert Oswald Moon, in his 1912 book "Prognosis and treatment of diseases of the heart," said:
True, indeed, Raymond Vieussens of Montpellier (1641-1716) was able to recognize disease of the heart as the cause of affections termed asthma and hydrothorax, to note the characteristic pulse of aortic insufficiency and to describe mitral stenosis and the consequent stagnation of the blood in the vessels in the lungs... yet it was not till the invention of the stethoscope and increased practice of percussion that cardiac diseases began to be seriously studied by clinical physicians." (2, page vii, and viii)
According to Oswald, the following are symptoms of heart disease: (2, pages 107-111)
  1. Insomnia (trouble sleeping):  Treatment is hypnotics ( chloralamide, paraldehyde, trionol, etc.).  Morphia is also a good remedy, and also treats any pain that may be present. 
  2. Coughing (early sign): Treatment is drinks of hot water and seltzer; for hacking cough a concoction with codeiae and ipacec is useful
  3. Dyspnea (due to fluid in lungs), and occurs especially at night or when lying down: Treatmenet is avoidance of heavy meals in evening; mustard poltaces and dry cupping over the back and chest are also useful; inhalations of oxygen are useful (usually by mask); morphia; atrophine; digitalis to strenthen heart (increase blood pressure)
  4. Flatulence; treatment is thymol
  5. Vomiting is usually a fatal sign: If severe, abstinence of all food, and peptonized milk with brandy; stop digitalis; large doses of bismuth are beneficial
  6. Dropsy:  It's generally described as the tightening of the skin or body cavity due to an abnormally large quantity of water in the body cavity (6, page 3), such as the lower legs, ankles, etc. It's an old term for what is now referred to as edema.  Treatment is diuresis (make patieint pee); diaphoretics (make patient sweat); a milk diet has a diuretic effect; digitalis also acts as a diuretic; caffeine is also a diuretic; nitrate of potosh; diuretin; theobromine
  7. Wheezing (not noted by Oswald)
As you can well see, many of these symptoms are similar to asthma.  In fact, the symptoms of cardiac disease are so similar to those of asthma that doctors still to this day often confuse the two.  Although, treatment for the two diseases is quite different. 

For a quick review, cardiac disease is now generally referred to as heart failure, and it occurs when the heart becomes a weak pump.  As a result the heart cannot keep up with demands of the body, and blood flowing to the heart (preload) becomes backed up.  This results in increased pressure in the vessels in the lungs, and  pulmonary edema (fluid in the lungs) often results.

The first known person to describe pulmonary edema was Giorgio Baglivi (1668-1707) in 1669.  He described it in his book De Praxi Medica (On the Practice of Medicine), according to Hector O. Ventura and Mandeep R. Mehra in their article (3, page 6).  These authors quote Baglivi as saying:
Next to be considered is a dangerous disease of the lungs which is called suffocative catarrh.  It is caused chiefly by stagnation of the blood in the lungs and about the pericardium... in this kind of catarrh the patient has a cold, and pain in the chest, and difficulty in breathing, also interrupted speech, anxiety, cough, sterter (heavy snoring on inspiration), a widely spaced low pulse, foam at the mouth, and the like... The foam at the mouth is caused by impaired circulation of the blood about the lungs... hence (this kind) of catarrh comes from sudden stagnation of blood in the vicinity of the heart and lungs, and not from phlegm running down from the head as the ancients believed to be the condition in this disease." (3, page 6)
In this way, Baglivi used Harvey's theory that the blood circulates to confirm vieussens theory that cardiac asthma and pure asthma are two distinct diseases.   The remedy used by Baglivi was bloodletting, as noted by Baglivi (per Ventura and Mehra):
An instant cure for this disease during the paroxysm is blood letting... The disease is very precipitous; unless phlebotomy is done immediately the blood coagulates more and stagnates.  Thus the opportunity for cure is lost.  The blood should be reduced in amount, the clotting should be undone, and a bland sweat should be produced.  (3, page 6)
Baglivi likewise believed that if an asthmatic, after three to four hours of sleep, awakens feeling as though he is suffocating, and opens the window for want of air, "consider it certain that he is suffering from dropsy of the chest."  The treatment for this, therefore, would be bloodletting.  The patient should also be encouraged to urinate (although Baglivi writes dysuria instead of diuresis), as lack of urination may lead to asthma, according to Baglivi.  Of course, as noted by Ventura and Mehra, Baglivi here is describing "nocturnal dyspnea" probably due to cardiac asthma. (3, page 6)

By the 1820s investigators had access to the stethoscope to listen to heart sounds and sphygmomenometer to monitor blood pressure.  This set the stage for Dr. James Hope, a cardiologist, who published a book in 1831 titled "A treaties on the diseases of the heart and great vessels."  In the book he described signs and symptoms of heart disease, including a description of how an overworked heart becomes hypertrophied, and  as it poops out blood gets backed up all the way to the capillaries of the lungs where it seeps out and causes pulmonary edema.  (3, page 7-8)

Hope recommended bleeding, emetics, purgatives, and expectorants. (3, page 8)  By the 1930s vodka was used to ease the foam of pulmonary edema (or foaming pulmonary edema, which often presents as pink, frothy secretions), and this was often used in emergency rooms to stabilize the edema bubbles which results in rapid dispersion of the bubbles.  Vodka (or ethyl alcohol) was useful for this until improved diuretics were available in the 1970s and 1980s.  (4, page 417)

The dose of alcohol was 3-5 ml of 30-50% ethanol alcohol (vodka) as needed, and it was diluted with probably 3cc of normal saline and aerosolized via a nebulizer.  It could also be delivered into the endotracheal tube (ETT) as needed.  (5, page 264)  Vodka was no longer used by the time I entered RT school, although I still often heard stories of how well it worked.  I would imagine this therapy was ceased due to possible side effects, and improved diuretics, such as furosimide (laxis).

Despite the revelations of Viessens and Baglivi, and despite many it would be many years before these two disease would be completely separated as unique diseases.  In fact, to this day there remain medical caregivers and practitioners who struggle with differentiating the two prior to further testing, and this often results in cardiac asthma (now called heart failure) being treated as asthma.

Various discoveries regarding the understanding of the heart and

*Arteries that feed oxygen to the heart.

References:
  1. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1921, 3rd edition, Philadelphia and London, W.B Saunders Company
  2. Moon, Robert Oswald, "Prognosis and treatment of diseases of the heart," 1912, London, Longmans, Green and Co. 
  3. Ventura, Hector O, and Mandeep R. Mehra, "Chapter 1: The history of acute heart failure management: how far have we come?" in the book "Managing acute decompensated heart failure," Christopher M. O'Conner, Wendy Gattis Stough, Mihai Gheorghiade, Kirkwood F. Adams Jr., editors, 2005, Taylor and Francis; 
  4. Burton, George G, John Elliot Hodgkin, Jeffrey J. Ward, "Respiratory Care: a guide to clinical practice," 1991, Lippincott
  5. Lough, Marvin D., Robert L. Chatburn, W. Arlen Schrock, "Handbook of Respiratory Care," 1983, Year Book Medical Publishers
  6. Monro, Donald, "An essay on the dropsy and its different species," 2nd edition, 1756, London, Plato's Head in the Strand
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