1873: Lebert creates new asthma theory

Herman Lebert (1813-1878)

In 1873, Herman Lebert came up with an interesting theory about asthma that lasted for several decades, and into the 19th century.  

Lebert was born in Germany, and later became professor of pathology in Paris and Zurich.  As a pathologist he spent hours in a lab investigating tissues under the microscope.  

Steven I. Hajdu, in a 2004 article in Annals of Clinical Laboratory Science, said Lebert was one of the first clinical pathologists who often goes unrecognized by pathologists, when he should be a household name to them.  (1)

Hajdu said he sliced"fresh tissues with a razor-like knife and prepared cell samples (smears) by scraping, washing, or by squeezing the tissue slices. Samples from fluids were placed on glass slides without preservatives. Most microscopic preparations were unstained, but occasionally a drop of iodine was applied as a stain." (1)

It was by this approach that he learned about cancerous tumors.  Hajdu said:

In his text on cancer (1851), Lebert gave concise summaries and organ specific descriptions of all forms of tumors. The book consists of 885 pages and discusses the dietary, surgical, and medical treatment of cancer. In 1857, Lebert published a comprehensive pathology text in two volumes that covered everything that was known at that time about anatomic pathology, as well as discussions on clinical pathology. (1)

Hajdu said it was Lebert's work, along with fellow pathologist Julius Vogel (1814-1880) who developed the "concepts of cellular pathology.  Vogel and Lebert established the solid basis on which Rudolph Virchow, in the 1860s, built his general theory about cells."  (1)

Despite his accomplishments, Hajdu said, Lebert (and Vogel too) does not get the credit he deserves, at least as far as pathologists are concerned.  This is yet another example of how history is not always written fairly.

Along with his other accomplishments, Lebert also did research on lungs and vessels, and he used this to establish opinions about asthma.

In 1873, he supported both the spasmotic theory of asthma and the diaphragmatic theory of asthma. However, he  believed asthma was caused by dilation of the blood vessels in the lungs. (2, page 45)

In fact, this theory was still believed to be true when epinephrine was later invented in 1900, as the vasoconstricting (vasopressor) component of epinephrine was thought to increase blood flow to the lungs to make breathing easier. (3, page 38)

Lebert also offered an interesting remedy for asthma. Rene Laennec, among other asthma experts of the 19th century, observed asthmatics often developed asthma at night, or in the dark.  Based on this observation, "Lebert advised the use of as many candles as possible in the rooms of asthmatics," said Orville Brown in 1917.(3, page 38)

References: 

1. Hajdu, Steven I, "The first cellular pathologists," Annals of Clinical Laboratory Science, 2004, http://www.annclinlabsci.org/content/34/4/481.full, accessed 3/11/14
2. Berkart, J.B., "On Asthma: It's pathology and treatment," 1878, London, J. & A. Churchill
3. Brown, Orville Harry, "Asthma, presenting an exposition of nonpassive expiration theory," 1917, St. Louis, C.V. Mosby Company

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1870: Biermer proves spasmotic theory once and for all

Michael Anton Biermer (1827-1892)

By experiments he published in 1854, Dr. M. Alton Wintrich convinced many physicians that asthma was caused by spasms of the diaphragm and not spasms of the bronchial tubes in the lungs.  Yet in 1870, experiments published by Michael Alton Biermer proved the spasmotic theory once and for all.

After Bert performed his experiments, Biermer ardently supported the spasmotic theory of asthma in a series of lectures in 1870. (1, page 194) (2, page 43)(3, pages 13-14) (5, page 11)

He believed the objections to the spasmotic theory of asthma based on the experiments of Bert "irrelevant," said Berkart, "for contraction of the thorax and the deficient resonance on percussion... could take place only if asthma were a spasm of the alveoli.

Along with the theories put forth by Bert, he proved that irritation of the vagus nerve caused contraction of bronchial muscles.(6, page 4)

According to Orville Brown he also "says that asthma is the result of swelling of the bronchial mucosa and a consequent obstruction of the smaller bronchi; the residual air in the alveoli then develop a greater tension and causes thereby a reflex spasm of the bronchial musculature. He reports a patient whose asthmatic seizures ended after the expectoration of a small feather." (16, page 34)

Thorowgood said:

Biermer observes that the bronchial muscles antagonise the muscles of inspiration, and so prevent over distension of lung. When, by frequent attacks of spasm, the nutrition of the bronchial muscles begins to fail, they no longer are able to antagonise the force of inspiration; or, by their contraction, to assist expiration, and thus that permanent condition of lung distension known as emphysema is brought about. (4, page 7)

Biermer published his wisdom on asthma in his 1870 book "Ueber Bronchioalasthma," and with Joseph Coats in the 1876 book "On bronchial Asthma."

References:

1. Geddings, W.H., author of the chapter on "Bronchial Asthma," in the book "A System of Practical Medicine," edited by William Pepper and Louis Star,Volume 3, 1885, Philadelphia, Lea Brothers and Co.
2. Berkart, J.B., "On Asthma: It's pathology and treatment," 1878, London, J. & A. Churchill
3. Thorowgood, John C., "Asthma and Chronic Bronchitis: A New Edition of Notes on Asthma and Bronchial Asthma," 1894, London, Bailliere, Tyndall, & Cox
4. Thorowgood, John Charles, "Notes on Asthma," 1878, 3rd edition, London, J and A Churchill
5. Dobell, Horace, "On Asthma; Its Nature and Treatment," 1886, London, Smith, Elder & Co.
6. Shmiegelow, Ernst, "Asthma, considered specially in relation to nasal disease," 1890, London, H.K. Lewis

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1865: Dr. See supports diaphragmatic theory of asthma

Germain See (1818-1896) was a German physician wrote several articles on asthma and other lungs diseases in the various medical publications of his era, and he is referenced more than once in this asthma history.  It is obvious, that through his writings, he was well acquainted with respiratory disease, including our asthma.

In 1865 he gave his support to the ideas of Alton Wintrich and Heinrich Bamberger that asthma was not caused by spasms of the muscular fibres in the lungs, and instead was caused by spasms of the diaphragm. (1, page 5) (2, page 2) 

In his 1890 book, Ernest Shmiegelow said See reviewed all the theories of the day.  He quotes See:

"Asthma is a neurosis in the medulla oblongata, that is to say in the centre of respiration, caused by an acquired or native elevated reflex irritability in this organ. The cause of the attacks must be sought for in irritations, which originate in pneumogastric nerves or other peripheral nerves. The effect of the reflex exhibits itself in the motory nerves of the inspiratory muscles, specially those of the diaphragm. We have, therefore, before us a permanent neurosis, whose attacks are caused by an irritation especially of the pneumogastric nerves, and which is always concluded by a tetaniform contraction of diaphragm, this theory only (in contrast to the bronchial spasm) can explain the dilatation of the lungs... The principal factor in the asthmatic attacks is therefore not (as in the bronchial spasm) a direct motor effect of the pneumogastric nerve, only the sensitive pneumogastric fibres take a part in this respect as they lead the irritation up to the noeud vital of the spine, whence the irritation spreads through the nervi phrenici to the diaphragm. " (1, page 9-10)

Joseph Berkart, in his 1878 book, said See divided asthma into three elements: (2,page 2)

1. Dyspnoea
2. Bronchial exudation
3. Emphysema of the lungs (2, page 2)

See believed asthma was always accompanied by organic lesions, and diseases such as chronic bronchitis and emphysema, but never caused by them. (2, page 37)

While others, such as George Kidd, believed asthma was a symptom of emphysema or chronic bronchitis, See believed it was, according to Berkart: (2, page 37)

...always a substantive disease, accompanied, but never produced by organic lesions. He recognised, however, only one form of it. In his opinion, asthma was essentially a neurosis of the vagus and its branches, and manifested itself by a tetanus of all the respiratory muscles, and by a bronchial exudation. The presence of these two "elements" combined was alone characteristic of the affection, whereas emphysema of the lungs was only their constant attendant. Emphysema, he maintained, was not an essential, but merely the consequence of the inspiratory traction during, and the bronchial exudation after, the attack.

Berkart said a goal of German experts, such as See, was, to...

"...maintain that, to warrant a diagnosis of pure bronchial asthma, the bronchial mucous membrane should appear healthy, nor should any other cause for the dyspnoea be discoverable. Still, not all supporters of this definition adhere to it throughout. They admit that asthma may be complicated 'with' or 'grafted on' other cardiac and pulmonary affections. But, as these affections are themselves capable of producing asthmatic seizures, the distinction in a given case between this symptom and the supposed complication would be purely arbitrary." (2, page 3)

In other words, according to Berkart, pure bronchial asthma was only diagnosed when there were no other scars found upon the lungs or the heart, at least according to the Germans. (2, page 3)

References:

1. Shmiegelow, Ernst, "Asthma, considered specially in relation to nasal disease," 1890, London, H.K. Lewis
2. Berkart, J.B., "On Asthma: It's pathology and treatment," 1878, London, J. & A. Churchill
3. Brown, Orville Harry, "Asthma, presenting an exposition of nonpassive expiration theory," 1917, St. Louis, C.V. Mosby Company; reference used: ee, Germain: Nouv. Diet, de Med. et de Chir. Practiques, 1865, iii, p. 585, pages 36, 89
4. Gee, Samuel, A lecture on permanent asthma, delivered at the Hotel Dieuj, by Prof. Germain See, translated from the Union Medicale, by H. McS. Gamble, "Gailard's Medical Journal," volume 37, edited by Edward Samuel Galliard, 1884, New York

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1865: Bamberger supports diaphragmatic theory of asthma

Heinrich von Bamberger (1822-1888)

Heinrich von Bamberger was an Austrian pathologist who provided evidence, similar to Duchenne before him, that he said supported the diaphragmatic theory of asthma.

Born in Prague in 1822, he earned his medical degree in 1847.  He worked as a pathologist at the University of Wurzburg and, beginning in 1872, at the University of Vienna.  (1)

While he wrote two books that were well received by the medical community, including his 1857 book "A Treaties on the Diseases of the Heart," he also published a book for physicians in 1865 sharing his knowledge of asthma called "Ueber Asthma Nervosum."  (1)

He supported the theories of Alton Wintrich, Guillaume Benjamin Amand Duchenne, and Michael Anton Biermer.  Joseph Berkart, in his 1878 book "Asthma: It's Pathology and Treatment," said:

In a case of fatal dyspnoea he had occasion to observe the tetanus of the diaphragm, and to convince himself by post mortem examination, of the absence also of structural lesions. Although the symptoms of that case by no means resembled those usually assigned to asthma, he, nevertheless, regarded them as characteristic of the disease. Reviewing then the theories held on the nature of the affection, he arrived at the conclusion that the presence of the bronchial muscles did not warrant the assumption of a bronchial spasm. If this existed, he would expect to find the diaphragm ascended, the intercostal spaces drawn in, and a dull resonance on percussion; indeed all the physical signs described by Williams and Bergson in conformity with their theory. But, as yet, he had never met with a case presenting those symptoms. So far as his observations went, he had always found dilatation of the thorax and hyper-resonance on percussion. These signs could be accounted for only by assuming a tonic spasm of the diaphragm and the auxiliary muscles of respiration; and he therefore inclined to the opinion of Wintrich, Duchenne, and Valette. (2, page 36-37)

Berkart said Bamberger further divided asthma:

• Central: Nervous asthma that causes tetanus of the diaphragm (he also beleived that paralysis of diaphragm was a cause of asthma, especially in cases of muscular atrophy observed by Duchenne.) (2, page 37)(3, page 7)
• Peripheral: Asthma that accompanies emphysema, bronchitis, pleuritic effusions and tuberculosis (2, page 37)

Other physicians who supported the diaphragmatic theory of asthma were Lehmann, George H. Kidd, and Germain See.  (2, page 37)

So you can see that the diaphragmatic theory of asthma garnished some very respectable support during this era.

References: 

1. "Bamberger, Heinrich von, "The Encyclopedia Americana," 1920, compliments of wikisource, http://en.wikisource.org/wiki/The_Encyclopedia_Americana_(1920)/Bamberger,_Heinrich_von, accessed on 3/6/14
2. Berkart, J.B., "On Asthma: It's pathology and treatment," 1878, London, J. & A. Churchill; Berkart references the following: Ueber Asthma nervosum: Wiirzb. Mediz. Zeitsch., Bd. vi, 1868, p. 102-116.
3. Thorowgood, John Charles, "Notes on Asthma," 1878, 3rd edition, London, J and A Churchill

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1675:Willis narrows asthma definition

Thomas Willis (1621-1675)

In the 19th century Dr. Samuel Gee (1839-1911) made a gallant effort to update the definition of asthma for physicians during his era. He wrote fondly of 17th century physician, Dr. Thomas Willis, giving him credit as "innovator of the doctrines of the ancients." (1)

Gee described, in 1899, that prior to the 17th century, asthma was considered "any kind of panting, gasping, pursy breathing such as follows on running on exertion." (1)

Back then asthma was still considered to be a disease nothing more than a disease caused by the spirits. Yet in 1678, Willis described asthma as "obstruction of bronchi by thick humors, swelling of their walls and obstruction from without." (2)

So Willis was given credit for the evolution of asthma as more than simply a disease of dyspnea and wheezing.  Other doctors may have helped to advance the definition (such as van Helmont), yet it was Dr. Willis who made asthma a unique illness in and of its own, such as Tuberculosis and Epilepsy were unique illnesses treated with unique remedies.

"Hence," Gee wrote, "Asthma and dyspnea were synonyms for most of the older physicians.  A few, such as Celsus (25 B.C.-50 A.D.), signified by asthma the highest degree of dyspnea, but this was all; asthma was never regarded as a special sort of dyspnea." (1)

For Gee, ancient definitions of asthma from Hippocrates to Galen to van Helmont were inaccurate until we get to Thomas Willis of the 17th century.  In his book , "Rational Pharmaceutic," which was published the same year as his death in 1675 (note the trend),  Willis explained that all ancient and modern physicians up to his time acknowledged only one kind of asthma, and this was pneumatic asthma.

Gee explained that pneumatic asthma was described by Willis as when the lungs were "obstructed or not open enough."  Gee said that the ancients regarded all asthma as "pneumatic and dependent on bronchial obstruction." (1)

He said the ancient definition of asthma is of little value in modern times (for Gee modern times would be 1899).  Yet, "It is interesting to note that those most conservative of people, the illiterate, continue to use the word in the sense of Hippocrates and Galen." (1)

However, we must note that it was illegal for the Ancient Greeks and Romans to dissect human bodies, and even in the 17th century it was very risky business to publish ideas that opposed the beliefs of the church or ruling parties (hence the publishing of Willis's works posthumously).

We see this often as we follow the history of science, medicine, and asthma.  It's perhaps this stubbornness of mankind that we can give credit for the slowness to which the term asthma was defined, and why it took until 1901 for good asthma medicine to be discovered.

Orville Harry Brown, in his 1917 book, explained that Willis attributed to the cause of asthma "as some humor in the blood. (5, page 27).

Ernst Shmiegelow, in his 1890 book, said Willis may have been one of the first to explore the idea of the diaphragm as being the cause of asthma, and therefore may also be the creator of the diaphragmatic theory of asthma which will be defined later in this history.  (6, page 4)

Gee said Willis described three forms of asthma: (1, page 817)

1. Pneumatic Asthma:  Dyspnea is a result of air passages in the lungs being obstructed or not open enough
2. Convulsive Asthma:  The primary fault of dyspnea comes from the lungs themselves, "in the moving fibres or muscular coats of the air vessels or in the diaphragm and muscles of the chest or in the nerves of the lungs and chest or of the origin of those nerves in the brain."
3. Mixed Asthma:  Both pneumatic and convulsive.

Gee said that in defining convulsive asthma, Willis pondered all the theories before his time and incorporated them into his newly defined convulsive asthma, which...

...was soon laid hold of.  The term 'asthma' came to be reserved for the exclusive denomination of that form of the disease which was believed to be spasmotic; and this is the sense in which the word is still used by most persons even in our own day.  (1)

I must continue to remind my readers that nervous asthma was generally thought to be synonymous with spasmotic or convulsive asthma.  By this the medical community believed the the fit of asthma was caused by nervous pathways from the brain as a result of something exciting these nervous pathways.

Barry Brenner, in 1999, said Willis also made an "association between food, emotion, heredity, and asthma." In fact, it was in 1672 that Willis described emotion as bringing about an asthma attack.  (3)

Way back in the 12th century, Maimonides described asthma as a nocturnal disease. In the 17th century there were many references of asthma as a nocturnal disease. T.J.H. Clark, in his 1987 book called "Diurnal Rhythm of Asthma, said Willis....

...blamed the heat of the bed as the cause of nocturnal asthma and he advised leaving the bed and sleeping in a chair.  By contrast, Maimonides recommended celibacy. (4)

So, while we know Jean Baptiste van Helmont was the first person to write about nervous asthma, Willis is given credit.  Regardless, the ideas of van Helmont and Willis regarding asthma would grow roots in the minds of the medical community that would impact how asthmatics were treated long into the 20th century.

References:

1. Gee, Samuel, "Bronchitis, Pulmonary Emphysema, and Asthma,", Lancet, March 25, 1899, page 817
2. Salvi, Sundeep S., "Is Asthma Really Due to a Polarized T Cell Response Toward a helper T-Cell Type 2 Phenotype," American Journal of Respiratory and Critical Care Medicine, Oct. 15, 2001, vol. 164, no. 8, pages 1343-6
3. Brenner, Barry, "Emergency Medicine," 1999, New York, page 6 (Brenner wrote 
4. Clark, T.J.H., "Diurnal Rhythm of Asthma," (American College of Chest Physicians), 1987,  page 1375
5. Brown, Orville Harry, "Asthma, presenting an exposition of nonpassive expiration theory," 1917, St. Louis, C.V. Mosby Company
6. Shmiegelow, Ernst, "Asthma, considered specially in relation to nasal disease," 1890, London, H.K. Lewis
7. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1921, 3rd edition, Philadelphia and London, W.B Saunders Company
8. Ramadge, Francis Hopkins, "Asthma, its species and complications, or researches into pathology or disordered respiration; with remarks on the remedial treatment applicable to each variety; being a practical and theoretical review of this malady, considered in its simple form, and in connection with disease of the heart, catarrh, indigestion, etc." 1835, London,  Longman, Rees, Orme, Brown, Green, and Longman; Ramadge discusses Thomas Willis's views on asthma on pages 93-94.  He also mentions him various other times in his book. 

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