Tuesday, May 30, 2017

1918: A killer worse than a war

Figure 1 -- People infected with the Spanish Flu
In 1918 two wars were raging. One was was reported on daily in the newspapers, and most families new at least one person sent off to battle. The other was a surreptitious pest that didn't stop on the battlefield, traveling around the world, infesting anyone in the vicinity of its victim.

The surreptitious war was waged by a killer that was not seen by the naked eye. Scientists new about virus's, yet they had never seen one as the electron microscope hadn't been invented yet.  They had yet to learn about DNA and RNA, "the genetic material of viruses."  They didn't know the lungs were the ideal burrowing ground for the influenza virus due to an enzyme there that, once connected to a cell, allows the virus to "split one of its proteins during teh manufacturing of new virus particles."  (1, page 27-28)

Figure 2 -- Chart showing mortality from 1918 influenza
pandemic in the U.S. and Europe (published 2006)
So there were some wacky theories postulated as to what caused the Spanish flu.  One theory was that a so called Pfeiffer's bacillus caused it.  At Chelsea Naval Hospital north of Boston the Pfeiffer's bacillus was present in the throats of 80 percent Spanish Flu victims autopsies.  It was the accepted theory, even though other victims didn't have the bacillus.  (4, page 271)

The Pfeiffer bacillus was first discovered by the man who named it, Richard Friedrich Johannes Pfeiffer, in 1892.  It was a small rod-shaped bacteria that he found in the upper respiratory tract of patients infected with influenza.  With the germ theory being well known by this time, many didn't doubt the claims of Pfieffer. (Wikepedia, will find a reliable reference later)

Figure 8 -- Burying flu victims, North River, Labrador (1918)
We now know Pfieferr's bacillus as Haemophilus Influenzae.   Later studies confirmed it's a bacteria that it normally lives in humans without causing disease, although in the right circumstances is known to cause a variety of diseases, such as eppiglotitis.  (Wikepedia)

While the cause was being debated, the Spanish Flu continued to make it's way around the world, aided by the ignorance of the populace.  It was transferred from one person to another when it was exhaled, coughed or sneezed into the surrounding air, and inhaled by another person.  This surreptitious killer was a new and powerful strain of influenza.

Influenza was the last thing on anyone's mind, mainly because it was considered minor ailment, and it had been more than twenty years since the last pandemic.  The flu was considered a "minor inconvenience" compared with the smallpox or yellow fever.  It was so minor that the government didn't require new victims to be reported, and so there was no way of knowing a new pandemic was raging, until the bodies started to stack up. (3, page 5)

Figure 3 -- Men in an Alberta field wear masks during the Spanish flu,
Fall 1918, Canada.  Masks were made of gauze or cloth
It was called the Spanish flu because it was believed to have started in Spain. Although the truth is no one knows where it started.  In Spain it was called the "three day fever."  The rest of the world called it the Spanish flu, probably because Spain was a neutral state, and it was among the few European nations "that did not censor its news reports."  Yet before long the flu had spread to all of Europe, Asia, and the United States.  (1, page 10)

It hit hard.  While the flu normally kills 1.5 percent of its victims, mainly the very young and the very old with weakened immune systems, the Spanish flu was different: it killed men and women with fully developed immune systems:  people who we think of as being healthy and strong enough to fight off the virus; people strong enough to fight in a war

Figure 4 -- Patient's at Walter Reed Hospital are separated by sheets.  Nurses
wear cloth masks over mouth and nose (circa 1918 or 1919)
It was normal for the flu to spread fast through military barracks, prisons and schools.  But the Spanish flu was aided by a war, with thousands of troops huddled together in trenches.  These men traveled all over the world, carrying the virus with them.

Within 2-3 days of contact with the virus, they started showing the typical signs of flu: headache, fatigue, sore throat, aches and pains, dry cough, fever and chills.  Yet these typical signs progressed in some victims to chest discomfort, pneumonia, and then cyanosis of the fingers, toes and then face.

The pneumonia caused bleeding in the lungs, and the victims would cough up blood.  Their faces turned dark blue, and their toes black.  These were ominous signs that usually resulted in death from suffocation.  And unlike regular pneumonia, death from pneumonia caused by the Spanish flu was quick, sometimes in less than 48 hours. (3, page 8)

Perhaps it was the helpless feeling of watching these people suffocate that provided one of the reasons why many studies were performed during WWI on oxygen therapy, and oxygen equipment greatly improved.  By the 1920s oxygen was available in hospitals to treat diseases that caused hypoxemia, although to the victims of the Spanish Flu in 1918 this was of little help.

Figure 5 -- Spanish Flu public notice from 1918
The Center for Disease Control (CDC) provides us with the following statistics regarding the Spanish Flu (2):
  • A third of the worlds population (500 million persons) were infected
  • Greater than 2.5 % of those infected died, as compared to the average flu virus killing 1.5%
  • Total deaths are estimated anywhere from 50 million to 100 million
The most significant statistic is the last one there: over 50 million people died.  This made the Spanish Flu the worst pandemic in the history of the world.  Compare that with the following (1, page 7):
  • 11.7 million died in the first 25 years of AIDS
  • 9.2 million died in combat deaths in WWI
  • 15.9 million died in combat deaths in WWII
Figure 6 -- Policemen wearing masks provided by the
American Red Cross in Seattle, 1918
Basically, the only remedy was to wait it out and hope you, or the ones you loved or were taking care of, survived.  A remedy tried was to inoculate "troops with vaccines made from body secretions taken from flu patients or from bacteria that they thought caused the disease.  They made them men spray their throats each day and gargle with antiseptics  or alcohol.  They hung sheets between beds, and at one camp they even hung sheets in the centers of thh tables at mess halls.  At Walter Reed Hospital, soldiers chewed tobacco each day, believing that it would ward off the flu."

While the origin of the Spanish Flu is unknown, some have developed conspiracy theories that postulate that the governments attempt to prevent the flu by giving such vaccinations were what caused the deadly strain in the first place.  We have heard stories of worse things being done by the Germans later, in the 1930s.  Yet such an attempt may have been performed in just about any country, including the United States.  Yet such conspiracies were never proven, and probably never will be.

Figure 7 -- A street car conductor iSeattle in 1918
refusing to allow passengers aboard
 who are not wearing masks
Another attempt to prevent the spread of the Spanish flu was to require people to wear masks made of gauze or cloth.  The problem with this is these masks often gave people the courage to go out into public places, and the virus was so resilient that it would make it's way right around the masks.  It was airborne, tiny enough, and wicked enough to do such a thing.

The Spanish flu went away as fast as it arrived, probably because it infected all the people who were vulnerable.  Eager to forget the dreadful events that just occurred, many newspapers refused to publish anything about the flu.  People were eager to put it behind them, and move on with their lives

Yet the Spanish flu had a major effect on society.  It interrupted society and economies all over the world, where people stayed home to care for their friends and relatives, and to keep themselves from getting the flu.

It also impacted the health care industry, whereas the government from then on required new epidemics of the flu to be reported.  Much of the way the influenza virus is kept in check today is based from researchers and scientists studying the outbreak of 1918.

Later, during the 1930s and 40s antibiotics and sulfa drugs were discovered to prevent and treat bacterial infections.  This made it so people who developed pneumonia as a complication of the flu could be treated and cured.  These medicines made the influenza bug less likely to be a killer.

Today we also have the ability to create an influenza vaccine and have it ready to give to people at high risk, if the strain can be isolated soon enough.  The problem that continues to plague scientists is there are many strains of the flu, and to inoculate against all of them wouldn't be cost effective.

Figure 9 -- "Demonstration at the Red Cross Emergency
Ambulance Station Washington, D.C.,during the
influenza 
pandemic of 1918."
So for this reason scientists must continue to be vigilant.  When new cases are reported, they are monitored.  Each year the "suspected" strain of influenza is readied in a vaccine and recommended for anyone at high risk, which generally are the very old, very young, and caregivers.  Although, as the Spanish Flu reminds us, sometimes those at risk aren't the typical victim.

Further reading:
  1. Spanish flu creates the 'living room'
References:
  1. Kolata, Gina, "Flu," 1999, New York, Farrar, Straus and Girouxx
  2. Taubenberger, Jeffrey, David Morens, "1918 Influenza: the Mother of All Pandemics," Emerging Infections Diseases, Centers for Disease Control (CDC), http://wwwnc.cdc.gov/eid/article/12/1/05-0979_article.htm, accessed 11/26/12
  3. Crosby, Alfred, "America's Forgotten Pandemic: The influenza of 1918," 2003, United Kingdom, Cambridge University Press
  4. Wikepedia: all the photos for this post are from Wikepedia: The free online encyclopedia.  

Monday, May 29, 2017

1940-1960: The RT Profession Matures

ITA Logo (6)
The respiratory profession as we know it today was born in the 1940s.  This is the decade nursing assistants and orderlies, mainly the strong, male variety, were recruited to transport, set up, monitor, and clean oxygen equipment. This was the beginning of the inhalation therapy profession.  Those individuals recruited were called oxygen orderlies or inhalation therapists. 

These first inhalation therapists were generally trained on the job (and were called OJTS) and usually poorly understood the task they were undertaking. For the most part they were referred to as button pushers, meaning that the physician gave them orders and they did what they were told.

Although this must have become frustrating for the inhalation therapists were were up on all the modern inhalation therapy wisdom.  They must have yearned to question many physician orders, and perhaps even the efficacy of what they were ordered to do.  They must have yearned for the autonomy to do things that might better benefit their patients. Some might have found physicians willing and eager to accept their ideas, although most were probably unwilling to heed the advice of uneducated therapists who were often considered mere ancillary staff.

Perhaps it was for this reason that, said  R. Weilacher...
...On July 13, 1946, a diverse group of 'oxygen orderlies,' physicians, nurses, and other interested people met at the University of Chicago to form the Inhalational Therapy Association. The profession was born on April 15, 1947, when the Inhalation Therapy Association (ITA) was legally chartered as a not-for-profit entity in the State of Illinois. (6) 
1960s: Sister Mary Yvonne Jenn 
becomes the FIRST registered inhalation therapist
in the U.S. (Registry No. 1!) (10)
The ultimate goal of this organization was to better educate inhalation therapists and further improve credentials and respect for the new profession. Considering there were no schools that taught inhalation therapy, all this training was performed by the present staff and managers of inhalation departments.

Because they were eager to further understand the equipment they were using, and the patients they were trying to help, many inhalation therapists read periodicals written for the nursing and medical profession.  What they didn't learn by reading they learned by training from their superiors or by their own experiences and observations.

Weilacher said:
Because formal training programs had not yet been defined, the teaching of subordinates was an obligatory part of management. Essentially this form of instruction was usually limited to passing on information gleaned from a limited number of resources and isolated experiences. Though this obligation served as a chrysalis for perpetuating the clinical profession, unfortunately it preserved the biases, prejudices, and misconceptions of instructors who had no experience in scientific methodology. These misconceptions were easily adopted by upwardly mobile subordinates and readily perpetuated elsewhere. (6)
This theory may help explain many of the problems that continue to plague the profession to this day.  Yet there were now a group of professionals that ranged from inhalation therapists and managers to physicians who were pent on improving the profession.

In 1947, Dr. Albert Andrews of Chicago wrote a short book, "Manual of Oxygen Therapy Techniques," that "documented the purpose and structure of the hospital-based inhalation therapy department," said Weilacher. (6)

This book was studied and the methods described were used by managers throughout the country to organize their inhalation therapy departments.

Dr. Anderson was an "ardent proponent" that IT departments should be operated under the direction of a physician on staff.  But this system was short lived due to changes forced upon hospitals by a decrease in staff during WWII.  (6)

Shortly after the war, in 1948, Alvin Barach wrote the first book specifically aimed at the inhalation therapy profession (ITA).

Then, in 1950, Barach, Edwin Emma, and Vincent Collins published...
...formalized minimum standards for training programs in the 1950s.  They received support from the Committee on Public Health Relations of the New York Academy of Medicine.  In the document, they specified a curriculum and conditions of training.  They noted that in most medical schools inhalation therapy was rarely part of the curriculum. (9, page 1163)
The italics there were added by this blogger for emphasis.  This was one of the things that inhalation therapists started realizing as they gained experience and education.  Yet trying to convince the medical profession that a group of therapists and technicians with little formal education that they knew more about inhalation therapy than physicians was a daunting task, one that continues to plague the profession to this day.

A little less than a decade later, in 1956, the ITA started publication of the first magazine specifically targeted to the inhalation therapist, and it was called "Inhaltion Tharapy." (This magazine is now referred to as "Respiratory Care.")

During the 1930s oxygen was beginning to be piped into hospitals, although this mainly occurred only in larger hospitals.  During the 1940s this trend continued, and by the end of the 1940s many hospitals had piped in oxygen systems with large oxygen tanks placed outside their doors.  When a person required oxygen, all the therapist had to do was plug in the equipment to the specific adapter on the wall.

While such systems made life easier for the inhalation therapist, it also created the first threat that the profession might no longer be needed.  Thankfully, however, a new role for the inhalation therapist soon developed, and this arose out of a revolution that was taking place in operating rooms around Europe and the United States.

By the 1950s new anaesthetics had been developed, along with newer methods of anesthetizing patients.  This made it easier for surgeons to perform abdominal surgeries without having to worry that a patient might die during the operation due to anesthesia.  This resulted in a spike in abdominal surgeries.

Of course this spike in abdominal surgeries resulted in a spike in post operative complications, which included postoperative atelectasis and pneumonia.

After a series of studies it was determined that these complications were the result of inactivity due to pain and medications used to control pain.  Such patients were not taking in deep breaths necessary to keep alveoli open, and this was causing atelectasis.

This, coupled with lack of a good cough to clear secretions, made the lungs a breeding ground for germs, resulting in pulmonary infections such as pneumonia.

So a new role for the inhalation therapist and nurses was to work with these patients to encourage them to take deep breaths and to move around, even at the expense of pushing these patients to the pain threshold.

In 1952 the first intermittent positive breathing (IPPB) machines were introduced to the market.  These machines were initially used to ventilate patients during operations.  Rubber tubing from the machines was connected to a rubber mask that was held over the patient's face.  During longer operations the tubing was connected to endotracheal tube.

These machines eventually made their way to patient rooms where they were either connected to rubber masks or a cannula inserted into a tracheostomy.

A variety of companies tapped into this new market, resulting in a variety of IPPB machines.  The most common were the Bennet PR 1 and 2, and by 1955 the Bird Mark 7.

These machines, along with iron lungs, were used as ventilators during the 1950s, although the IPPB machines soon became more common.  It was the role of the inhalation therapist to manage both IPPB machines and the iron lungs.

With the advent of positive pressure breathing, various companies rushed to tap into this market to create machines that would eventually replace both IPPB machines and iron lungs.

These new machines were called volume ventilators. The Emerson Volume Ventilator was introduced to the market in 1964, and the MA1 Volume Ventilator that hit the market in 1967.

The Emerson ventilator was often referred to as a big green washing machine.  It had parts that were similar to parts inside a Volkswagon Beetle, and for this reason, when the machine stopped working, say a belt broke, a belt might be removed from the Beetle and replaced into the ventilator.  The machine provided humidification by means of a simple hot plate that could be repaired by parts bought at a local shop.

The MA1 was such a sturdy and compact unit that had simple knobs on the front where the therapist could dial in tidal volume and rate.  Alarms were added to these machines over time, and were usually more complicated to operate than the machines themselves, which were actually quite simple.  An MAI was actually still in service at the community hospital I started working for in 1997.  I used it only once before it was replaced with the Servo 300A.

Monitoring, maintaining and cleaning these machines was a complicated task, and it required the services of the inhalation therapist.  This, along with the routine use of IPPB machines to provide intermittent bronchodilator therapy to post operative patients and lung patients hospital wide brought added security to the profession of inhalation therapy.

So it was during the 1950s that IPPB therapy became routinely prescribed in hospitals worldwide.  Physicians would often order them to be used three to four times per day and as needed to force the lungs open in order to create better distribution of medicine in lung patients.

This type of therapy was although thought to force collapsed areas of the lungs open in order to prevent and treat post operative atelectasis and prevent post operative pneumonia.  So it became quite common for inhalation therapists to perform IPPB treatments to patients, and this was the beginning of the IPPB revolution.

The best part about this was that at this time there was a fee for each of these treatments performed, so inhalation therapy departments were quite lucrative for hospitals, further justifying the need to keep inhalation therapy departments intact.
Also during this time oxygen was being used routinely for hypoxia that resulted from diseases such as pneumonia, heart failure, chronic bronchitis, and emphysema.  Inhalation therapists, nurses and physicians were observing that some of their chronic bronchitis and emphysema patients were becoming lethargic, and sometimes dying, when exposed to high amounts of oxygen.

This observation gave birth to the fear that high levels of oxygen might knock out the drive to breathe in such patients who had a chronically elevated carbon dioxide (CO2) levels, and this gave birth to the hypoxic drive theory that would cause physicians to underoxygenate chronic obstructive pulmonary disease (COPD) patients for the next 40 plus years.

The hypoxic drive theory was proven by Dr. E.J.M. Campbell in the 1950s based on a study of only four COPD patients.  In a report to the physicians in 1960 he reported his findings, and ever since then medical students have had the hypoxic drive theiry pounded into their heads.

The nice thing about the hypoxic drive theory is it provided yet another reason for the importance of inhalation therapists.

It was about this time that it was observed that as ITs obtained more responsibility and were taking care of a greater number of disorders with oxygen therapy and IPPB therapy, that the scope of knowledge needed far exceeded their training. This was particularly apparent on weekends and night shifts when the least experienced therapists were working alone. (5)

Partially as a result of this, beginning in 1950 members of the ITA started teaching classes.  Initially there were 16 classes in total, and upon completion of an exam participants earned a certificate and became the first certified inhalation therapists.

Another thing that was new during the 1950s was cardiopulmonary resuscitation, or CPR.  Various studies were performed that proved that most adults who stopped breathing were having cardiac issues, and that the most effective means of oxygenating these individuals was by performing chest compressions.
bOther studies proved that mouth to mouth breathing was not only safe, but it was the best way to breathe for unconscious patients.  So chest compressions and mouth to mouth breathing became routine elements of CPR.

Another revolutionary breakthrough occurred in 1953 when the AMBU-bag was invented, allowing caregivers an easy and safe means for breathing for patients who were unable to do it on their own.  Performing CPR, and managing the airways by using AMBU-bags, became the routine task of inhalation therapists.

In 1954 the ITA was renamed the American Association of Inhalation Therapists (AAIT). Then, in 1957, members of the American Medical Association, American College of Chest Physicians, and the American Society of Anaesthesiologists adapted a resolution called "Essentials for an Improved School of Inhalation Therapy Technicians."   (8)

Completion of the program resulted in certification.  In October of 1960 the American Registry of Inhalation Therapists (ARIT) was formed to oversee examinations for formal credentialing for people in the field, and a multiple choice test was created with a requirement to complete an oral exam that tested the IT student's ability to use critical thinking skills in real life settings. (8) (9, page 1163)

The first person to fulfill all the requirements of these classes was Sister Mary Yvonne Jenn, who, in 1961, became the first Registered Inhalation Therapist (RIT). (9, page 1164)

References:
  1.  "Questions and Answers," The Modesto Bee, Thursday, Dec. 2, 1948
  2. Glover, Dennis W., "The History of Respiratory Therapy," 2010, page 40
  3. Branson, Richard D, "Jack Emerson:  Notes on his life and contributions to Respiratory Care," Respiratory Care, July 1998, vol. 43, no. 7, pages 567-
  4. Glover, ibid, page 48
  5. Wyka, Kenneth A, Paul Joseph Mathews, William F. Clark, "Fundamentals of Respiratory Care," 2001, page 10, "The Late 1950s and 1960s: Organizational and Clinical Maturation."
  6. Weilacher, Robert R, BHA, RRT, "The History of the AARC," aarc.org, http://www.aarc.org/member_services/history.html, accessed 10/26/12
  7. Whitnack, Jeff, "The History of Respiratory Therapy," AARCTimes, - Volume 26, Issues 1-6 - Page 66
  8. "AARC Timeline," https://www.aarc.org/member_services/timeline/, accessed 10/11/14
  9. Hess, R. Dean,  Neil R. MacIntyre, Shelley C. Mishoe, William F. Galvin, Alexander B. Adams, editors, "Respiratory Care: Principles and Practice," 2nd edition, 2012, Jones and Bartlett Learning, LLC, U.S.
  10. AARC Facebook page, https://www.facebook.com/aarc.org/?fref=ts, accessed March 3, 2016

Friday, May 26, 2017

1920-1940: The birth of the RT profession

Compared to physicians, who can trace their roots to ancient times, and nurses, who can trace their roots to Clara Barton's Civil War heroics, the profession of respiratory therapy is a relatively young profession that can be traced only as far back as 1922.

We could trace it back to 5,000 B.C. when Egyptians inhale fumes to gain breathing relief, or 100 A.D. when herbs were smoked in pipes in Ancient India, or even the 18th or 19th century when the first nebulizers and pressurized breathing machines were patented.

Yet the profession as we know it can only be traced back to 1922 when John Scott Haldane wrote about his research on oxygen in "The Therapeutic Administration of Oxygen." It was this book that sparked interest in the therapeutic use in oxygen to treat diseases.

Prior to the 1920s oxygen therapy equipment was purchased and/or put together by the physician, who would also set up the equipment, maintain the equipment, and also monitor the patient.   

By the 1920s physicians were working hard to lug large oxygen tanks from one room to another, and this task quickly became overwhelming for them, especially as they also had a practice and a home life that needed their attention.  

Yet by the 1920s, when oxygen tanks were available, doctors had to work hard to lug the tanks from one patient room to another. Patients who were set up on oxygen masks and oxygen tents and iron lungs needed constant attention and monitoring.   

Masks back then were made of black rubber, making it impossible to see if it was filling up with pulmonary edema or vomit, or if the patient was otherwise getting worse.  These masks were also known to stick to people's faces, further complicating their care.  

Therefore, to see if a patient was getting worse, these masks had to be removed from the patients faces on a regular basis. When this was done powder was placed around the mask to prevent it from sticking to the patients face.  (Glover)

This task became overwhelming for physicians, and so they recruited the assistants of nurses, and mainly female nurses.  It soon became the job of nurses to set up, manage, and maintain all the oxygen equipment, along with monitoring these patients.  And, of course, it was now their job to lug those large oxygen tanks and iron lungs from room to room, and then to clean all this equipment between patients.

Such caregivers also had to make sure the oxygen tanks still had oxygen in them, and this task was complicated by the fact that oxygen regulators were not always accurate.  If they didn't trust the regulator, they might have to change a tank even though there was plenty of oxygen in it.  

The first nonrebreather-type masks were made so these patients could get 100 percent oxygen, and they were made with two flaps with one way valves that prevented these patients from entraining room air. The problem with this system was that when a tank ran out without warning, these patients were prevented from getting air, and many of them suffocated.

To prevent this one of the flaps was removed.  In this way, if the oxygen in the tank ran out, the patient would still be able to entrain room air to prevent suffocation.  It is for this reason that nonrebreather masks to this day still only have one flap, and really, technically speaking, not truly nonrebreather masks but partial rebreather masks delivering only about 75 percent oxygen.  

Another problem developing at this time was that oxygen therapy had become so complicated and burdensome that knowledge of it was generally beyond the scope of a physician's knowledge. It mus also have been beyond the scope of a nurses knowledge.  The main reason that this was not because physicians and nurses weren't intelligent, but because most were educated and trained prior to the use of oxygen therapy, or before the oxygen revolution of the 1920s.    

So special training was required to learn how to set up, manage, operate it, transport and clean this equipment.  In most cases certain physicians and nurses were especially trained, and these physicians and nurses were in essence your first respiratory therapists. 

But keeping up with new knowledge in this era was always a challenge, especially for senior physicians who were skeptical of this new therapy and were resistant to change. 

So the job of managing oxygen equipment, which now included tanks, oxygen tents, and iron lungs, was doled off to nurses, mainly female nurses. 

By the 1930s managing patients with oxygen became routine, and large tanks were placed outside the hospital and piping systems were set up inside the walls to patient rooms.  This made it so nurses no longer had to lug tanks from room to room.
Also by this time, as physicians did a decade earlier, nurses started complaining of being overwhelmed by taking care of so many patients who were now requiring oxygen therapy, while at the same time having to manage all of their other patients.  It was for this reason that they started recruiting other hospital staff, particularly male orderlies and nurses assistants, to help them with all the oxygen related duties.  These orderlies in essence became your first true inhalation therapists, and the profession of inhalation therapy grew into its infancy.  (2)

Now, instead of trained physicians and nurses handling the job of oxygen therapy, the job was now performed people who had no medical training other than what they learned on the job.  These individuals were often referred to On Job Trainees (OJT).  

Because these OJTs were now taking care of patients and complicated life saving equipment, the need, the need arose for special training on oxygen equipment and how to care for patients requiring its use.  

Commercial companies who supplied the oxygen equipment, or physicians at the hospital itself, created programs to train OJTs to become inhalation therapists, who quickly became the experts on oxygen therapy.  

These specially trained OJTs were now separate from the other orderlies, and they began to meet with people with similar duties at other institutions. These orderlies, and nurses aids were now officially referred to as inhalation therapists, and sometimes as "oxygen orderlies." A young profession of inhalation therapy was born. (1, page 9)

References:
  1. Wyka, Kenneth A, Paul Joseph Matthews, John A. Rutkowski, editors,"Fundamentals of Respiratory Care," 2011, Delmar, New York, Cengage Learning,
  2. Glover, Dennis W., "History of Respiratory Therapy," 

Wednesday, May 24, 2017

1898: A doctor's humble request for help

So it's the year 1898 and you are a physician. One of your patient's has intractable asthma, where everything you prescribed failed.  What can you do?  Well, why not submit a letter to the editor to medical magazine asking for help. Here's one example of a doctor doing just that.
Editor Medical World :—I ask help for a case of simple but intractable bronchial asthma. I can find no complications. The patient is a lady, about 40 years old, weight 200 pounds, ruddy complexion, red hair. There is no hereditary taint. She is now five months pregnant, but the asthma does not seem to be much worse than before she became so. I have given her a good many remedies with only temporary relief. J. R. Mclaurin, M.D. Toomsuba, Miss. ,

A humble submission on the part of a doctor who had the best interest of his patient at hand. 

References:
  1. Taylor, C.F., editor, "The Medical World," volume 16, 1898, Philadelphia, page 251

Monday, May 22, 2017

1898: Physicians search for asthma remedies

Physicians in the 19th century were eager to find a good remedy to help their asthmatic patients, especially the children suffering from it.  There were no truly effective remedies for the ailment, although there were a few options that provided at least some relief temporarily.

I almost like to think of the asthma market in the the 19th century as the weight loss market of today.  Most people are busy and don't have time to exercise.  And with all the tasty foods, they don't want to diet.  So this opens up a market for weight loss gimmicks.

So now there's hundreds of products catering to this market, including pills, elixirs, weights that vibrate, and gadgets that wrap around your body to create perfect abs.  In reality, however, most of these products don't produce results unless the person has a calorie deficit, or consumes fewer calories than he burns.  

This was how the asthma market was in the 19th century.  Some medicines offered relief, but none made your asthma go away.  However, if you managed to avoid your asthma triggers, it may appear as though the medicine was working.

And much like the modern person yearns for an article or post in a magazine that describes the latest weight loss craze or gimmick, the 19th century asthmatic or asthma doctor yearned for the the latest asthma craze or gimmick.

One such post was included in the 16th edition of "The Medical World" as a letter to the editor:
Editor Medical World :—I wish we could get some of the able contributors to your valuable journal to contribute their experience in the treatment of bronchial asthma. It has been my lot to have several patients suffering with that disease. Fortunately for me, I have been very successful in treating it. The prescription that I give, with some variations, has wrought wonders in some of my asthmatics. As an example, about six months ago I was called to see a lady who was attacked with malarial fever, and while dosing out medicine for her, my attention was attracted to some one in the adjoining room who seemed to be making a desperate effort to get the breath. On inquiry I learned that the party was the lady's daughter, who had been a sufferer with asthma ever since she was six months old, and that she was then sixteen; and that the attacks were getting more frequent and lasted longer. I am giving the daughter the following prescription. Since she has been taking it she has had two slight attacks, which were promptly relieved by giving the medicine in double doses every four hours. This relieves the attacks generally when the second or third double dose is taken. The following is the prescription:
prescription:
B Iodide of potassium - - oz. iss
Muriate ot ammonia - - dr. iv
Fid. ext. grindelia robusta - oz. ij
Fid. ext. quebracho - - oz. iss
Fid. ext. jaborandi - - - dr. iv
Ammonia bromide - - oz iss
Simple elixir enough to make oz. viij
M. S. Take a teaspoonful three times during
the day and one at bedtime.
S. H. Singleton, M.D.
Fouts, Oklahoma Ter.
Similar to today's physicians, each has his own prescription for asthmatics.  The main difference is that today's physicians have access to better asthma wisdom, better asthma remedies, and asthma guidelines.  So while there are still a variety of options for treating asthma, physicians today are less open to playing around with crap shoot remedies as S.H. Singleton was looking for.

References:
  1. Taylor, C.F., editor, "The Medical World," volume 16, 1898, Philadelphia, page 26-27

Friday, May 19, 2017

1904: Wompole's Hypno-Bromic Comp will cure your asthma

By 1904 asthma was still a nervous affection, and a notable treatments were medicines to ease the mind. One such remedy was Wompole's Hypno-Bromic Comp.  

According to a 1904 article in the New Albany Medical herald:
"If you want to give your patient relief from asthma, and a good refreshing sleep from which he will wake greatly refreshed, Just try wompole's hypno-Bromic Comp.  It will give quick and satisfactory results. Give this relief to the next case of asthma you are called to treat." (1, page 584)  
Cocaine and morphine were often prescribed to help a nervous person sleep. But, ccording to an 1898 article in Medical Progress, Wompole's Hypno-Bromic Comp. not only worked better, but was safer.  The article mentions a case where morphine was trialed, although after a while it allowed the patient, a female, to "sleep an hour or two.  She was given a teaspoon of Wompoles Hypno-Bromic Comp. each night immediately after she had come out of the bath.  This remedy had a most happy effect."

Two other cases were also described, and the results were essentially the same.  (3)

A recipe for this product can be made in your own kitchen:. Here are the ingredients. 
Chloral hydrate gr. 480
Potassium bromide gr. 240
Extract of henbane gr. 4
Extractofcannabisindica.gr. 4
Morphine sulphate gr. 2
Simple syrup fl. dr. 4
Comp. spirit of orange. fl. dr. 1 Water, enough to make. fl.oz. 4 Make a concentrated solution of the chloral hydrate in water, triturate the extracts with this solution; add the potassium bromide and the morphine each dissolved in water, the spirit and the remainder of the water, and filter clear.(2)
This would have been just another option in the days when there were no ideal treatments for our disease.

References:
  1. "Medical Gleanings," New Albany Medical Herald, volume 22, No. 286 October, 1904, New Series Volume 11, Number 157 
  2. Hiss, Emil, "Thesaurus of Proprietary A recipe for this product can be found on page 271 of Emil Hiss's 1898 book "Thesaurus of Proprietary Preparations and Pharmaceutical Specialties," 1898, Chicago, G.P. Englehard and Company page 272
  3. "Suggestions on the management of nervous trouble," The Medical Progress: A monthly history and medical progress,John S. Moreman, M.D., editor, July 12, 1896, volume 12, new series number 79, old series number 126, pages 248-248

Wednesday, May 17, 2017

1889: Osler's asthma remedies

Dr. Osler's book "The Principles and Practice
of Medicine" was first published in 1892, and
was continually updated until 2001. 
Dr. William Henry Osler's recommended treatment for asthma didn't sway much from what other physicians of his day prescribed.  Since there really was no one medicine to resolve an asthma attack, which medicine to recommend was mainly based on personal preference.

However, Osler was among the first to note the urgency of treating asthma.  He said "immediate and prompt relief is demanded."  Remedies include any of the following:
  • A few whiffs of chloroform will produce prompt but temporary relief
  • Perles of nitrite of amyl may be broken on the handkerchief or 2-5 drops on cotton-wool and inhaled
  • Strong stimulants given hot or a dose of spirits of chloroform in hot whiskey will sometimes induce relaxation
  • Morphia or morphia with cocaine will produce more permanent relief (requires hypodermic injection). Good for obstinate attacks.
  • Antispasmotics, such as belladonna, stramonium, and lobelia in solution or cigarettes
  • Solanacae with nitrate or chlorate of potosh (common in most remedies)
  • Any form of asthma cigarettes (one form benefits one pt while another benefits another)
  • Nitre paper made with strong solution of potash.  "Filling a room with the fumes of this paper may sometimes ward off a nocturnal attack."
  • Tobacco smoke:  sometimes as potent as the prepared cigarette
  • Large meals early in the day as opposed to later
  • Coffee is better than tea
  • City is better than country
  • High and dry altitudes are more beneficial than sea shore
  • Oxygen may also be tried
  • City living was better than country living
Osler was among the first to recommend oxygen for the treatment of asthma, yet while epinephrine (adrenaline) was discovered in 1901, updated editions of his book prior to his death did not mention this quick acting medicine.

Many historians have  noted that Osler was unique in that he mentioned that "death from the attack is unknown."  However, many asthma experts during the 19th century, including Henry Hyde Salter, made similar observations.

References:
  1. "Sir William Osler At Seventy -- A Retrospect," The Journal of the American medical Association," 1919, Saturday, July 12, pages 106-108
  2. Osler, William, "The Principles and Practice of Medicine," 1892, New York, pages 497-501
  3. Bliss, Micheal, "William Osler:  A Life in Medicine," 1999, New York
Further readings:
  1. Jackson, Mark, "Asthma: The Biography," 2009, New York, pages 211-12
  2. Brenner, Barry E, ed., "Emergency Asthma," 1998, New York, pages 212-14

Monday, May 15, 2017

1889: Osler defines asthma

William Osler is often referred to as the
Father of Modern Medicine.  He shared his
medical knowledge in 1896:  "The Principles
and Practice of Medicine
William Henry Osler is considered by many as the Father of Modern Medicine. He shared his medical knowledge in his 1889 publication "The Principles and Practice of Medicine."  It is from this book we can still delve into his mind to see what he was thinking about various diseases, including our own: asthma.

It was his ideals about medicine that transformed the way medicine was taught.  He was well respected by physicians around the world, and his word was considered like words from the Bible.

In this way he was able to settle many debates about medicine, and push forward new ideas that were scientifically solid and old ideas that continued to have merit in the newly founded scientific world of medicine.

While he didn't have much new to add to asthma wisdom, he set the standards for future practice and research in this area.  He believed the following to be true about asthma and allergies:  (1):
  1. It's of nervous origin
  2. Various triggers set off an acute attack
  3. Attacks involve swelling of bronchial mucus membrane
  4. Attacks involve constriction of bronchial muscles
  5. Attacks involve increased secretions 
  6. Flow is obstructed by this swelling, constriction and increased secretions
  7. Asthma and allergies are similar in origin and unique in their symptoms
  8. Asthma and allergies are hereditary
  9. Many asthmatics present with allergies (hay fever)
  10. Children are more affected than adults
  11. Men are affected more so than women (1)
As with Frances Rackemann, his ideas about asthma being a nervous condition sent many researchers and scientists down the wrong path, and may ultimately have delayed progress in the field of asthma. He wrote that "the affection sometimes runs in families, particularly those with irritable and unstable nervous systems."

Yet his understanding of the benefits of science in medicine would prove to benefit asthmatics.

Further reading:
References:
  1. Osler, William, "The Principles and Practice of Medicine," 1892, New York, pages 497-501

Friday, May 12, 2017

1889: William Osler: The father of modern medicine

Sir William Henry Osler
The turn of the 19th century was the dawn of modern medicine. So medicine needed a father, and the man to step into that role was Sir William Henry Osler.

Due to the significance and respect for his character, the ideas he wrote about were seriously considered by the medical community, including what he wrote about asthma

The growth of a legend:

Willie Osler was born to a family with a prominent history. His father was an Anglican minister, and Osler's goal was to follow in his father's footsteps It was this goal that landed him in 1867 at Trinity College in Toronto.

Yet this was also a time when physicians and scientists were using science to disprove some old ideas about science and medicine.  Charles Darwin proposed an idea that challenged the age old idea of natural selection, and chose to believe science instead.  Science was in direct competition with religion.

Perhaps it was for this reason that Osler's heart just wasn't in the ministry.  He spent most of his free time reading about medicine.  His heart, and perhaps fate,  lead him ultimately to switch from studying ministry to medical school where he excelled.

He started Medical School at Trinity College where the methods of teaching medicine were primitive and left to the desires of each respective professor. The college hospital admitted only 25 patients at a time, and medical students could only see patients taken care of by their own physician. (3, page 54)

Once Medical School was complete after three or four years young physicians had little experience working with real patients, and the young Olser took acceptance to this.

Osler believed pathology was essential to improving medical wisdom.
Like other physicians before him, he would have been befuddled by the
lack of scarring caused by asthma.  This must have been what caused him
to deduce, as others had before him, that asthma must be nervous.
For this reason, much of the treatment focuses on the nervous component
Much of his time was spent studying and performing autopsies. He was often so involved in his work that he ate in the same room he performed these autopsies. His goal was to learn as much as he could about the human body and medicine.

Most of the classes were taught by local physicians, and payment for these classes was given directly to the professor. Lectures were mainly given from old medical textbooks and were "flung at us pellmell without word of guidance, and leaving us standing helpless, bewildered, and starved in the midst of what seemed a superabundance of wealth," wrote Osler.  (3, page 54)

He ultimately transferred to McGill University where his writings, research and ideas quickly won the attention of his fellow students and professors.  He continued to study, research and perform autopsies (while eating in the same room).

During his final year in med school he worked so hard on his graduation thesis on pathologic anatomy that he was rarely seen by his fellow students  His theses would ultimately win accolades "because it was greatly distinguished for originality and research." (1)

It was partly because of this work and the potential in the young Osler that he was offered a job as a teacher at McGill University. But he declined, choosing instead to attend school in Europe to further his medical wisdom. He did his studies in Vienna and Germany, which were considered to be leading nations in medicine and science at that time.

In 1874 he returned to Canada, and, coincidentally, one of the medical professors at McGill University had resigned.  At the young age of only 25, and with very little experience as a physician, Osler was offered and accepted his first teaching job.  Within a year he was named as a professor of medicine.

He wasn't paid enough money to make a good living as a teacher, so he had to start a practice.  Yet he ultimately became so rapt in his job as a teacher that he gave little attention to his medical practice and other opportunities to make money.  However, he did manage to see patients, including many famous ones. 

His enthusiasm allowed him to get the most out of his students, and he became an instant hit as a teacher.  A year later he became one of the seven founders of the Association of American Physicians, and in 1889 he became one of the first physicians at John Hopkins University.   It was here that his career took off.

A transformation in medicine:

John Hopkins was built on the idea that it would be the best medical hospital in the world. To run its medical school Henry Osler was hired based on his reputation and his bold ideas for the medical profession.

This turned out to be a wise decision, because it was Osler who came up with the idea that medical students learn best when working with actual patients.  He often repeated the maxim:   "Listen to your patient, he is telling you the diagnosis."

While other medical schools were unorganized and offered two or three year programs, John Hopkins would offer a four year program that required a year as an intern working alongside physicians in the medical ward to obtain experience working with real patients.  .

 Osler became rapt in medical wisdom, and loved to share this wisdom.
 Here he is writing "The Principles and Practice of Medicine"
This was the first time this was ever done, and it was a big hit.  It was such a big hit that within a few years many medical school were transforming the way they taught medicine.  No longer would physicians graduate from medical school when their only experience was from lectures, textbooks, and a few random patients.

Through all this time Osler continued to do what he loved best, and that was to study the human body by performing autopsies and reading books.  He spent a ton of time in the morgue, laboratory and library.  He likewise continued to write about what he learned through his experiments and observations.

During his career he wrote over 750 contributions to the medical world of literature, including a the first textbook of Internal medicine published in 1892:   "The Principles and Practice of Medicine."  While he didn't know it at the time, it would end up being the last medical book written by just one person.

Osler would continue his work until his death in 1919, yet not before he became a legend in his own time. His name was known by physicians throughout much of the world. The debate had already begun as to whether he was the greatest physician to ever have lived.

Click here for more asthma history.

References:
  1. "Sir William Osler At Seventy -- A Retrospect," The Journal of the American medical Association," 1919, Saturday, July 12, pages 106-108
  2. Osler, William, "The Principles and Practice of Medicine," 1892, New York, pages 497-501
  3. Bliss, Micheal, "William Osler:  A Life in Medicine," 1999, New York
Further readings:
  1. Jackson, Mark, "Asthma: The Biography," 2009, New York, pages 211-12
  2. Brenner, Barry E, ed., "Emergency Asthma," 1998, New York, pages 212-14

Wednesday, May 10, 2017

1878-1885: Asthma no longer a confused term

By introducing the art of percussion to his medical practice, Jean Corvisant realized that many cases of asthma were actually diseases of other organs.  When his student, Rene Laennec, introduced percussion with auscultation to his practice, he quickly observed that asthma was truly an abused term.

These are the two 19th century asthma experts we can thank for giving us the tools necessary for differentiating asthma from other diseases and diagnosing it as a disease.  In other words, prior to the 1820s anything that caused dyspnea was regarded as asthma, and after the 1820s asthma was more carefully diagnosed.

It is by these discoveries that asthma is divided into different categories, each of which ultimately became disease entities of their own:
  • Cardiac Asthma: Dyspnea due to heart disease is now heart failure 
  • Kidney Asthma: Dyspnea due to kidney disease, now known as kidney failure
  • Bronchitic asthma: Dyspnea due to chronically inflamed air passages and excessive sputum production, now known as chronic bronchitis
William Pepper and Louis Star published a book in 1885 called "A System of Practical Medicine.  In the opening pages they explain the following: 
Ignorant to a great extent of pathological anatomy and unprovided with the improved methods of physical diagnosis which we now possess, they (previous asthma writers) described as asthma not only the dyspnoea due to cardiac and pulmonary diseases, but also that occasioned by affections of the pleura and greater vessels. Covering such an extensive range of territory, it was found necessary to subdivide the disease into a number of varieties, each author classifying them according to his conception of the cause, seat, and nature of the trouble. Some of these—e. g. a. dyspeptic-urn—still find a place in medical literature, but the vast majority of them, having ceased to be of any practical significance, have been discarded, and are now only interesting as examples of the crude and fanciful notions which prevailed in an age during which science rather retrograded than advanced. Of the writers of this period, Willis in the seventeenth century is especially worthy of notice as being the first to describe the nervous character of asthma. Without discarding the accepted forms of the disease, he mentions another variety, characterized by spasmodic action of the muscles of the chest, to which he gave the name asthma convulsivumThe improvement in physical diagnosis resulting from the brilliant discoveries of Auenbrugger (percussion) and Laennec (stethoscope) greatly curtailed the domain of asthma with the aid of auscultation (use of stethoscope to hear lung sounds) and percussion it was discovered that most of the cases hitherto regarded as asthma were only symptoms of some organic disease.  (1, page 184)
J.B. Berkart, in his 1878 book "On Asthma: It's pathology and treatment," wrote the following:
ALL early historical traces of the affection at present called asthma are lost. Although the disease is said to be mentioned in the Bible, and described by Hippocrates, Areteaus, Galen, and Celsus, there is not the least evidence that those remarks apply to the asthma of to-day. For in the former systems of medicine, all cases presenting the same conspicuous symptoms were, regardless of their anatomical differences, considered as of a kindred nature, and grouped into classes according to imaginary types. (2, page 12)
I know these quotes are almost trivial, yet I find it interesting because these physicians, in this era, were privy to the idea that they were taking part in the rapid evolution of the definition of the disease they were studying -- asthma. Or, more accurately, they were seeing the evolution of differential diagnosis of the various disease processes that often result in dyspnea.

In essence, Laennec's discovery sparks a leap through time.  Where 7,000 years of asthma suffering resulted in little progress in the way of asthma wisdom and treatment, the next 81 years -- part of which we are now observing -- provides for asthmatics more than all those 7,000 years combined. I think that Pepper and Star and Berkart and most other authors of pulmonary diseases in this era were well aware that this was happening.

And we learn that between 1816 and 1900 many different theories about what causes asthma are created, and every one of these theories has followers.  Each expert wrote his own definition of asthma based on his beliefs about the disease, and his own experiments and observations, and his own remedies based on these beliefs."

By the various proofs, by the various debates, that transpired during the 19th century about the disease we call asthma, and of other related diseases, it resulted in a significant fine tuning the definition of asthma.  Yet in the end, the two theories that won the day were:
  1. Spasmotic theory of asthma (a.k.a. bronchospasm or convulsive): There was evidence to support it
  2. Nervous theory of asthma (a.k.a. it's all in your head): There was no evidence to disprove it.
Or, more commonly, that these two theories of asthma were intertwined, such that some mysterious event or object (such as a certain food, a full stomach, laughter, strong emotion, excitement, dust, or cat) excites the nervous system, which in turn sends a message to the bronchial muscles to contract.

By the end of the 19th century the ground was set for an even bigger leap through time as far as asthmatics are concerned.  By 1899 adrenaline was isolated, and this sets off a wave of wisdom that greatly improves the lives of asthmatics. Yet for the time being (no pun intended), we find ourselves drifting from cozy doctor's 

References:
  1. Pepper, William,  Louis Star, "A System of Practical Medicine," Volume 3, page 184
  2. Berkart, J.B., "On Asthma: It's pathology and treatment," 1878, London,  Chapter II, "History of Asthma," page 12

1879: Berkart describes turning point in asthma history

If I could get my time machine fixed, I would travel through time to the year 1878.  That was the year that Dr. J.B. Berkart published his book "On Asthma: It's Pathology and Treatment." On the day Berkart pulled that first book off the press, he must have admired his work with a smile.  I would have liked to have seen that.

Berkart, as you may have noticed already, is a significant contributor to our history of asthma, particularly as it wends it's way through the 19th century.  In fact, Berkart was among the first to point out that much of what was known about asthma prior to the 19th century should have no bearing on our modern quest to define this disease.

Of this, he wrote the following in his introduction:
The so-called bronchial or spasmodic asthma is, to this day, perhaps the most obscure of all diseases. Not withstanding the attention which asthma, on account of its frequent occurrence and the suffering it entails, has ever received at the hands of physicians, hitherto all their endeavours to elucidate the subject have only led to divergent opinions upon even the most essential points, and to the development of incongruous theories. Indeed, it is not saying too much that, among them there are not any two who fully agree in matters of either observation or inference; but all hold views at variance with one another, while each contends that only his own are consistent with facts, and in harmony with rational pathology. (1, page 1)
Later, as he walks his readers through the history of asthma, he pretty much skipped through 99% of history of asthma, and simply wrote this:   
All early historical traces of the affection at present called asthma are lost.  Although the disease is said to be mentioned in the Bible, and described by Hippocrates, Areteaus, Galen, and Celsus, there is not the least evidence that those remarks apply to the asthma of to-day.  For in the former systems of medicine, all cases presenting the same conspicuous symptoms were, regardless of their anatomical differences, considered as of a kindred nature, and grouped into classes according to imaginary types.  Thus intense but intense and intermittent dyspnea formed the typical characteristic of the class asthma; and this, with its numerous species and varieties, comprised a promiscuous collecting of diseases having absolutely nothing in common but one symptom.  In that sense, however, the term asthma was employed until the commencement of the present century, so that even, at so late a period, empyema and dilation of the heart were described as asthma paradoxon and asthma nervosum.  Moreover, as before the invention of auscultation and percussion, marked functional disturbances were the sole means of diagnosis, their close similarity in all diseases of the chest must have necessarily rendered an accurate distinction between the several known forms of them impossible. (1, pages 12-13)
By that paragraph, Berkart pretty much sums up our asthma history to this point.  Essentially all that was known about asthma prior to the introduction of percussion and auscultation should simply be ignored. Observations of asthma prior to this time could have been may have been asthma as we think of it today, or it could have been just about any other ailment that causes dyspnea. Or, as noted by Dr. Chevalier Jackson in 1947, "All is not asthma that wheezes." (2, page 128)

Dr. Berkart was a London Physician at the City of London Hospital for Diseases of the Chest, and was one of the foremost experts on asthma at that time.  He must have been, as he accepted the honor of taking over the series of books started by his successor: Dr. Henry Hyde Salter.  

Berkart then describes the events that inspired further investigations into the actual pathological causes of asthma:
It is only after percussion began to be practised that asthma can more clearly be discerned in history. As soon as certain cardiac affections, hitherto imperfectly or not at all known, were by means of it recognised during life, it became at once evident that the dyspnoeal attacks which accompany them were not of nervous origin, as was until then supposed, but were the necessary consequence of the structural lesions. Corvisart,who was the first to perceive this fact, was moreover led to infer that of the prevailing forms of nervous asthma, several, if not all, probably arose in'an analogous way. But his means of diagnosis were as yet too limited to prove that supposition.
The task was thus reserved for Laennec.' His invention of auscultation brought physical diagnosis to such a degree of perfection as to enable him to determine the true value of the numerous forms of the "asthme des praticiens", and to range them in their proper places as mere symptoms of anatomically defined diseases. Yet in that sweeping measure hecould not comprise the intermittent attacks of dyspnoea, of which no adequate cause was discoverable by means of the stethoscope.(1, page 13)
So the climax of our asthma history was when Corvisart and Laennec introduced percussion and auscultation to the medical profession. It was only after this time that a true definition of asthma could be discerned.
While we may have suspected this earlier, Berkert articulated this perfectly.

If I could get this darn time machine fixed, I'd travel back in time to that day when Berkart held that first copy of his book.  I would like to be there and watch as his lips curled upwards as his fingers caressed the warm, crisp hot-off the press book with his name on the cover.

References:
  1. Berkart, J.B., "On Asthma: It's Pathology and Treatment," 1878, London, J.& A. Churchill
  2. Miller, Hyman, "Physiological basis for the treatment of asthma," California Medical, March, 1947, 66 (3), pages 128-30

Monday, May 8, 2017

1878: Thorowgood supports Salter's asthma theories

Dr. John Charles Thorowgood wrote a book called "Notes on Asthma" that went through a variety of editions.  Probably due to a wave of new evidence learned about the disease, the later editions were called "Asthma and Chronic Bronchitis, which sheds light for historians on the evidence clearly separating these two diseases.

Thorowgood's basic description of asthma is not far removed from the theories postulated by Dr. Henry Hyde Salter, that: (1, page 1-2)(2, page 16)
  1. The main component of an asthma attack is spasms of the unstriped contractible fibres (bronchial muscles) that wrap around the bronchi that results in narrowing of these air passages
  2. That the main cause of such spasming is due to a nervous disorder, as can be confirmed by autopsy when an asthmatic dies: no lung scarring can be found.  This lack of any evidence of disease clearly indicates asthma is nervous in origin.  There are two routes the nerves can cause asthma:
    • Central Nervous System: Some exciting cause, probably emotional, triggers the asthmatic response, and causes narrowed air passages. 
    • Reflex Action: Something stimulates the vagus nerve or pneumogastric nerve, such as overeating, forced expiration (coughing or laughing)
He also agrees with other physicians of his era, Salter included, when he writes the following: (1, page 2)(2, page 16)
During the intervals between his attacks the patient probably enjoys fair health, and, as a rule, lives to a good age; should he, however, be cut off prematurely by death, what do we find as the morbid anatomy to explain the wellmarked symptoms seen during life?
In other words, he believes that pure asthma is intermittent in nature, allows the patient to live a relatively normal life between attacks, and that asthma rarely causes death.  In the rare cases asthma does cause death, the asthma is not pure: it is associated with some type of morbid condition such as chronic bronchitis or heart failure.

He describes an attack this way: (1, page 2)(2, page 16)
He defines asthma as symptoms "distressing enough to endure or to witness; and yet, when things seem to be at their worse, and the patient well-nigh at his last gasp, a remission comes on, the spasm yields, air enters the lungs, and the attack subsides, coincidentally often with access of cough and mucous expectoration." 
He likewise agrees with Salter that while pure asthma may present with no structural changes, that after years of repeated and violent attacks, "cannot but lead to some alteration of tissue, and the microscope will probably show some granular or fatty degeneration in the air cells of the lungs, though to the naked eye appearances may be normal." (1, page 3)(2, page 17)

So in the rare event someone does die from asthma, it will be due to some form of organic changes that take place after years of asthma attacks.  Either that, or it was some organic change, such as occurs with chronic bronchitis and heart failure, caused the asthma and ultimately lead to that person's death.  (2, page 17-18)

These are things that both Salter and Thorowgood agree upon.

References:
  1. Thorowgood, John C., "Notes on Asthma," 1878, 3rd edition, London, J & A Churchill
  2. Thorowgood, John C., "Asthma and Chronic Bronchitis: A New Edition of Notes on Asthma and Bronchial Asthma," 1894, London, Bailliere, Tyndall, & Cox

Friday, May 5, 2017

1876: Dr. Beard: Nervous theory of hay fever

Hay-fever sufferers, much like asthmatics, look like normal, healthy people between episodes.  Actually, they might even look normal during episodes. So once the disease was defined by John Bostock in 1819, physicians were quick to conclude that hay-fever, like asthma, was a nervous disorder.  Yes, your hay fever is all in your head.

Well, surely your symptoms weren't all in your head.  The itchy eyes, nose and throat, the watery eyes, the sniffling, sneezing and wheezing are real.  But the cause of your symptoms is indubitably caused by a  a nervous temperament.  Surely you can get the condition without being nervous, but this was more the exception than the rule.

It appears that the champion for the nervous theory of allergies is our good friend, the physician George Miller Beard, the standing head of the United States Hay Fever Association. He explains that: (1, page 77)
"In order to induce an attack, there is necessary first of all a predisposition, frequently hereditary, to special and excessive sensibility of the nerves supplying the affected parts.
"The debilitating influence of heat and the external irritation of a large number of vegetable and other substances are exciting causes merely, widely varying in their effects with different individuals, and of themselves are powerless to induce, or at least to sustain, an attack. As the disease depends mainly on the individual predisposition, no two cases will be precisely alike, but all will differ as individuals differ."
Now, it is important to note here that by implying that hay fever sufferers are "nervous" in no way am I implying that people who have hay fever are goofy in the head, or mad or insane.  This is farthest from the truth.  Dr. Beard explains: (1, page 85)
"Skepticism of this sort comes from an entire misconception of the meaning of the term nervous. Nervousness is assumed to signify debility—of body or of mind, or of both; and to show itself by paleness, emaciation, and incapacity for muscular or cerebral toil. Of all popular delusions, none are more baseless than this. The nervous temperament—even the nervous diathesis, and various manifestations of that diathesis—may coexist with an imposing physique, and with both the appearance and the reality of high health. Physiology and pathology may thus go hand in hand; few people are wholly sick or wholly well; in certain directions we maybe diseased or liable to disease—in all other directions we may be almost absolutely strong."
So the underlying disposition among hay fever sufferers is a nervous temperament, and this predisposes them to the effects of a variety of causes, such as dust, ozone, plants, flowers, grasses, hay, animals, and of course pollen.

Evidence?  Yes, you want evidence.  Dr. Beard provides the following:
  1. It's hereditary character:  Because it runs in families makes it nervous.  "From this we justly conclude that the disorder is of a constitutional character, in the sense that a tendency to it is innate in the organization.  Since dust and pollen don't trigger hay fever in most people, they are thus deemed tetriary or secondary causes.  The primary cause must be something inert, like the nerves.  The descendents of those who suffer from it are the ones most likely to also suffer from it.  "Parents who are of the nervous diathesis, and who illustrate this diathesis by sickheadache or hysteria, may have children and grandchildren among whom prevail many nervous symptoms, of which hayfever is but one."(1, page 79-81)
  2. It prevails mostly among those who have nervous diathesis:  People most likely to have it have stressful brain jobs, are educated, upper class, and have an "active emotional nature," and it seems to "develop with the progress of civilization...As would logically be expected, it is oftener met with in cities than in the country, is more marked and more frequent at the desk, the pulpit, and the counting-room than in the shop or on the farm."  It is more likely to be prevalent in those who "overwork" the brain (brain or desk job) as compared to overworking the muscles (outdoor job, farming). It is more prevalent in the nervous melancholy person (the thinker) as compared to the relaxed phlegmatic person (the relaxer).  (1, page 81-87)
  3. It is peculiar to modern civilization, and most prevails in most climates and countries where other functional nervous diseases prevail:  "We have seen already that hay-fever is a disease of the nineteenth centuryit has arisen side by side with neuralgia,with nervous dyspepsia, and allied disorders, of which the eighteenth century knew little or nothing.* There are physicians who can recall the time when neuralgia, now the heir-loom of all well-to:do families, was an unknown word, and when nervous dyspepsia, now so common as to excite no comment, was unheard of."  Hay fever is also seen more in the U.S. and Britain, countries that are more civilized.  Some in Europe call it the English disease, considering it's more prevalent there than in other less civilized countries of Europe. (1, 87-89)
  4. The symptoms of the disease, from first to last, through all the stages, are largely of a nervous character, and are made better or worse by mental influences: Consider the following nervous symptoms prevalent in most, but not all, hay fever victims: (1, page 90)
    • Lassitude
    • Sleeplessness
    • Poor appetite
    • Depression
  5. It sometimes appears to take the place of other diseases, and to be replaced by them:  Physicians have noted that patients with upset stomach, for example, noted their symptoms of that ailment went away as soon as the hay fever struck, and returned when hay fever symptoms disappeared.  Ironically, I have noted this same thing.  I once remember telling my mom I have never been nauseated and short of breath at the same time.  It's an interesting observation and I can see by my own personal experience how it might be thought of.  (1, page 92)
  6. It is affected for better or for worse largely by those influences that operate through the nervous system:   The remedies of the symptoms prove the illness is "under the influence of the mind.  Symptoms come on during periods of overwork and emotion, and remedies to relax the patinet seem to make the symptoms go away.  Likewise, "the remedies that thus far have been of the highest service for the relief of the symptoms, as quinine, arsenic, electricity, stramonium, alcohol, opium, ether, are pre-eminently nerve remedies, and in all the diseases for which they are used accomplish their results directly through the nervous system. Hygienically it is found that cold, of any kind or from what ever source—cool land-breezes, cool sea-breezes, the coolness of elevations or high latitudes, or a cellar or dark room —never fails to relieve; and for a large number of nervous states cold is one of the most potent of tonics."  (1, page 92-94)
  7. Three factors are needed for hay fever symptoms to be present:  Symptoms are only present when all three of the following are present (removal of any one makes the symptoms go away, or not appear): (1, page 94)
    • Predisposition
    • Heat
    • External irritant (dust, pollen, etc.)
  8. Like other functional nervous diseases, hay-fever appears to be excited more by heat following cold than by continuous heat:  Geographic regions where the weather changes around the year, as it does in the tropics, the poles, and northern U.S., have a greater incidence of hay fever sufferers.  Such changes in temperature cause exhaustion, and this stimulates the nervous system.  Geographic regions that are consistently warm have lower rates of hay fever, such as the northern parts of U.S., the tropics and the poles.  So "warm climates are the best resorts for nervous people."  (1, page 95) 
Usually, attacks of hay fever only come about when you are exposed to these causes, animals or vegetable.  In most regards, this therefore makes hay fever more or less a seasonal disease, as most of the predisposed matter are only present at specific seasons of the year, such as the summer or fall, hence the terms "summer catarrh" or "fall catarrh."

Therefore, "as the disease is not due to any single specific cause, animal or vegetable, as has been supposed, no specific will ever be found for it," states Dr. Beard. "As with ordinary asthma, sick-headache, and other neuroses, to which it is in some respects analogous, the attacks may be prevented and relieved, and some remedies will act specifically for individuals; but no one remedy will ever be found to relieve all cases." (1, page 78)

Considering there is no proven cure, the following have been tried with some success (1, page 78):
  • Avoidance of exciting causes (heat, light, dust, worry, animal irritants)
  • Fortifying the system by tonics before and during the attack, and relieving the symptoms by those sedatives and anodyne, locally or generally administered, which are found by eperience to be bet adapted for each individual cae
  • Spending the season of the attack:
    • At sea; preferably in high altitudes, here the air is always cool, invigorating, and entirely free from vegetable and animal irritants
    • In elevated mountainous regions, where in all latitudes the air is cooler and more invigorating than at low elevations, and some at least of the vegetable irritants are less abundant.
    • In high latitudes, at any elevation where the air is sufficiently cool.
    • At the sea-shore, or on islands near the coast.
    • For those who can not leave their home, keeping quiet in cool, closed, darkened rooms.
When the above remedies don't work, or for those who cannot afford to take such a vacation, the following are remedies that can be tried before and during the attack: (1, page 78)
  • Local applications:
    • Quinine 
    • Arsenic
    • Iron
    • Electricity
  • Atomization:  
    • Quinine
    • Camphor 
    • Palliatives (Remedies that experiment shows to be most useful for each individual.
One may also use just about any remedy that proves to have palliative effects on the symptoms of the disease, notes Beard.

Beard also makes a bold prediction about the future of hay fever:
These facts relating to the transmissibility of hay-fever are the more astonishing when taken in connection with the fact that the disease is so recent. There has scarcely been time as yet for the malady, so to speak, to get intrenched in families, for our grandfathers never heard of this trouble, except, perhaps, as a distant and doubtful wonder, while at the present time it is increasing with such rapidity that in twenty-five years, it is safe to say, there will be thousands of families who have more than one representative in the hayfever army. (1, page 80)
It's interesting anyway.  While Beard and other experts of his era were wrong about hay fever being nervous, Beard was correct when he predicted a steady rise of hay fever sufferers in the future.

Yet, it is true, writes Beard, that "hay fever is, then, a disease of the fashionable and the thoughtful -- the price of wealth and culture, a part of the penalty of a fine organization and an in-door life." (1, page 87)

References:
  1. Beard, George Miller, "Hay-fever; or catarrh: it's nature and treatment," 1876, New York, Harper and Brothers