Wednesday, May 10, 2017

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

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