1837: Stokes defines chronic bronchitis

William Stokes (1804-1878)

In 1837 Dr. William Stokes became the first to use the term "chronic bronchitis" in his book "The Diagnosis and Treatment of Diseases of the Chest." (8, page 45)

He defined bronchitis as "inflammation of the mucous membrane," and that this condition may give rise to "dilations of the air cells and tubes, and to pulmonary emphysema."  (8, page 45)

He also said bronchitis is evident in nearly all diseases of the lungs.  In noting this, he was drawing a similarity with bronchitis, pneumonia and asthma.

Like Laennec, Stokes was among the first to explain the relationship between chronic bronchitis and emphysema, and believed bronchitis lead to emphysema. He was also the first to describe different types of sputum, such as mucoid and mucopurulent.  (1, page 86).

He also mentioned increased secretions and chronic cough as part of the condition.

References

1. Qutayba Hamid, Joanne Shannon, James Martin, "Physiologic Basis of Respiratory Disease," 2005, Montreal, page 85-99
2. Stokes, William, "The Diagnosis and Treatment of Diseases of the Chest," 1837, Dublin

1856: Sales-Giron invents first nebulizer

Dr. Sales-Giron's portable nebulizer (5)

Dr. M. Sales Giron, of Pierrefond, France, is given credit for inventing the first portable nebulizer.  (8, page 461)

According to Mark Sanders at Inhalatorium.com, the device had a pump handle that operated like a bicycle to draw liquid from a reservoir and forced it through the atomizer.  This provided a fine mist for the patient to inhale whatever medicines were in the reservoir.  (1)

This idea actually came about because the main ways for people to inhale medicines in the mid 19th century was by either inhaling the smoke or steam of volatile medicine.  Doctors knew that many non volatile medicines would also be of use for diseases of the airways, and the only way to get the medicine to the lungs was to produce a mist. (8, page 461)

James Prosser, in his 1884 book "The Therapeutics of Respiratory Passages," said a mist would work well for non volatile and volatile medicines because "it carries with it particles of solids (the medicine) as it may contain in solution." (3)

This concept was first thought up when persons observed that when a rapid stream of water hits a rock a spray or mist is produced that can be inhaled.  The idea that this could be used for the inhalation of medicine was first played with by Auphan at the spa of Euzet-Les-Bains in in 1849.  (9, page 184)

At such spas, mineral water was put over heated rocks and the steam was inhaled. Prosser said:  (2)

"The idea of atomizing the mineral waters seems to have originated, or at any rate to have been first carried into effect, by Auphan at (the spa of) Euzet-les-Bains in 1849; he projected a jet of the mineral water on the wall of the inhaling room with sufficient force to break it up into a spray, which was inhaled by his patients. This method was adapted at several spas."

The July 30, 1870 edition of The Medical Times and Gazette reported that the so called inhalation room was often referred to as an 'inhalation saloon,' and by this means did actually charge the atmosphere with the spray, or, as he termed it, the 'pulverized' or 'atomized' water.  (4)

The problem with inhalation saloons, as Prosser notes, was the difficult proving actual mineral waters were being used or just plain water.  This method of treatment was generally determined to be "ineffective" and "not suitable for private practice."  (8, page 461)

Figure 1:  The original Sales-Giron Nebuliser

So the market was open for a device that would allow a person to create a mist of mineral water in his own home.  M. Sales-Giron was charged with the challenge of inventing such a device by M. de Flube, owner of a watering place at Pierrefond. (9, page 184)

Sales-Giron worked on this project for many years, and finally introduced his final product to the Academy of Medicine in Paris on May 20, 1856. In Pierrefond a Sales-Giron Inhalatorium was opened where 1-15 patients could inhale the mist at the same time.  (9, page 185)

By 1858 he introduced to the market a portable device that could be used anywhere. In it any medication could be used to produce a spray "as fine as the mist created in an Inhalatorium. (9, page 187)

He referred to it as "Pulverisateur portatif des liquides medicamenteux."(8, page 461)

The original product can be seen by the woodcut in figure 1, and is described here:

It consists of a vessel filled with the fluid to be atomised, while above it is placed an air-pump, A, which compresses the air above the surface of the water, the pressure being indicated by a manometer, c. When the instrument is at work the fluid escapes through the fine opening of a tube with a stopcock, D, and strikes against a small metal disc, E, where it is broken and turned into a very minute vapour, any of the condensed vapour escaping through a small tube, G. (8, page 461)

The device is also described by Dr. John Milton Scudder in his 1867 book "On the use of medicated Inhalations in the treatment of diseases of the respiratory organs."  He said:

"(The instrument is) so constructed that the medicated fluid is forced, by the agency of compressed air, through a tube having a very small opening against a metal plate. At this point the steam of fluid is checked, and it becomes divided into fine spray, (to which the term of pulverized, or atomized, has been applied), and in this condition can be inhaled by the patient." (5, page 23)

While it appeared to be a great idea, something asthmatics had waited thousands of years for, it was slowly accepted by the medical community.  One of the main concerns at the time was whether the mist actually made it to the lungs.

Prosser writes:

"But at length Sales-Giron constructed a portable apparatus for atomising fluid, and brought it before the Academy of Medicine of Paris n 1858. This was undoubtedly an epoch in the history of inhalations, and the greatest interest was excited. It was not, however, until 1862 that the committee of the Academy appointed to investigate the new method brought in its report, and during the interval prolonged discussion had taken place as to whether the spray penetrated deeply into the air passages. The report stated that it was proved that both the water and the mineral constituents employed penetrated not only to the bronchi but even to the air-cells; and this report was founded on extensive independent experiments and was almost unanimously adapted by the Academy. The conclusion and practice of Sales-Giron, who has been called the Father of Atomization, thus received the highest authority and rapidly spread over the civilized world. Demarquay was one of the earliest to adapt it, and to prove independently that atomized liquids rapidly pass into the respiratory passages." (2, 6)

Prosser said that the device was later improved upon by Dr. Lewin, Dr. Bergson, Dr. Siegle and Dr. Baigel.  I will write about their devices in a later post.

However, one problem with the device was it was large, fragile, and expensive.  Another major obstacle was that it was hand powered and difficult to use.  For this reason none of these original nebulizers were readily accepted.

References:

1. Inhalatorium.com, "Sales-Giron's Pulverisateur," viewed April 30, 2012
2. Prosser, James, "The Therapeutics of Respiratory Passages," 1884, New York, pages 281-282
3. Prosser, ibid, page 284
4. "The Progress of Therapeutic Science," The Medical Times and Gazette: A Journal of Medical Science, Literature, Criticism and News," volume II for 1870, 1870, July 30, London, John Churchil and Sons
5. Scudder, John Milton, " On the use of medicated Inhalations in the treatment of diseases of the respiratory organs," 1867, Cincinnati, 2nd edition, Moor, Wilstach, and Baldwin
6. "The Progress of Therapeutic Science," , ibid, provides a more precise description of the process of doubt and inevitable proof that the Sales-Girons nebuliser did get medication directly to the air passages is provided in this article.  See page 125
7. Picture compliments of Mark Sanders of the inhalatorium (inhalatorium.com
8. Beatson, George, "Practical Papers on the Materials of the Antiseptic Method of Treatment," Vol. III, "On Spray Producers," Coats, Joseph, editor, "History of the Origin and Progress of Spray Producers ", Glasgow Medical Journal, edited for the West of Scotland Medical Association, July to December 1880, Vol. XIV, Alex and Macdougall, pages 461-484
9. Cohen, Jacob Solis, "Inhalation in the treatment of disease: it's therapeutics and practice," 1876, Philadelphia, Lindsay and Blakiston

1887: The infamous Dr. Gee

Samuel Gee (1839-1911)

When I was a student at Ferris State University in 1990 I had a philosophy teacher who made sure we were not one second late for class.  I was reminded of him as I learned about the punctual Dr. Samuel Jones Gee.

The Historic Hospital Admission Records Project (HHARP) said:

"His reputation as a teacher was second to none, and his punctuality the stuff of legend. He was leaving his house in a cab one day, when a patient detained him. As the conversation continued, the door of the vehicle swung open, hit a tree, and fell off its hinges. He insisted on carrying on to Bart’s minus the cab door, so that he would not be late." (1)

He was born in 1839 and developed a love for history, and because of this he became proficient in many languages, including Ancient Greek.  His ability to read and write in Greek would eventually benefit children around the world, as it allowed him to compare ancient accounts of diseases with what he observed during his own personal assessments and examinations on autopsy.

He attended college at University College School in London and studied medicine at the University College Hospital.  He impressed as a student enough to be hired as house surgeon at University College Hospital where he worked until 1865 when he earned his medical degree.

He was then hired at the Hospital for Sick Children, Great Osmond Street where he would eventually serve as pediatrician and pathologist.  He was passionate about learning about diseases and how to treat them, and he loved performing autopsies.

While his main job was working at the children's hospital, he also worked at St. Bartholemew's Hospital and managed to maintain a private practice.  A private practice back then involved the doctor traveling to the patient's home instead of the other way around as it is today.  So, while lucrative, it was a lot of work, and often quite risky.

He wrote 2 books and published 46 papers in St. Bartholemew's Hospital Report, with almost all of his writings on pediatric diseases -- which included asthma, bronchitis and consumption (tuberculosis).   HHARP mentions that one of the biggest complaints against him was he didn't write enough. (1)

He was best known for is a lecture he gave in 1887 in which he gave the first modern day description of coeliac disease, a condition that affected many of the children he treated.  He described the condition this way:

“There is a kind of chronic indigestion which is met with in persons of all ages, yet is especially apt to affect children between one and five years old. Signs of the disease are yielded by the fæces; being loose, not formed, but not watery; more bulky than the food taken would seem to account for; pale in colour, as if devoid of bile; yeasty, frothy, an appearance probably due to fermentation; stinking, stench often very great, the food having undergone putrefaction rather than concoction".

He learned a lot about this disease by reading ancient accounts written by Aretaeus of Cappaocia who was a master clinician about 100 A.D.  Areteaus was known for providing some of the first descriptions for many diseases, such as pleurisy, diphtheria, tetanus, pneumonia, diabetes epilepsy and asthma.

He was also the first to describe the symptoms of coeliac disease, although he referred to it as coeliac diathesis.  Gee chose to respect Areteaus and referred to the condition as the coeliac affection.  Today we refer to the condition as coeliac disease. (2)

The condition causes it's victims to become pale, weak and appear to be wasting away, symptoms similar to tuberculosis.  Aerateaus believed it only occurred in adults, yet Gee recognized it could affect anyone, although it was most common among children aged 1-5, which was one of the main reasons Gee became so enthralled by the disease.

Gee was the first to differentiate between coeliac disease and tuberculosis, and he brought coeliac disease to the mainstream in the medical world.  He was also the first to suggest the cause and cure might be in the diet. 

Coeliac disease is similar to asthma in that neither disease causes any changes in their respective organs.  Of Coeliac disease Gee wrote, "Naked-eye examination of dead bodies throws no light upon the nature of the coeliac affection: nothing unnatural can be seen in the stomach, intestines, or other digestive organs."

Aerateus had a theory as to what caused asthma, and he likewise had a theory for coeliac disease.  He believed a "natural or indwelling" heat was needed for proper digestion, or "pepsis" as he referred to it.  Pepsis was the natural breaking down of food which occurred in the heat.  (2)

Aeratus explained that Coeliac affection was caused by a "chilling of the natural heat needed for 'pepsis.'"

Gee didn't agree with this, although he didn't pretend to know a cause or remedy.  A cause and treatment of the disease alluded the medical world until the 1950s when the condition was linked to the consumption of gluten in the diet.

Coeliac disease is now considered an autoimmune disorders, and some say astma is too.

Dr. Gee passed away in 1911, yet many of his publications are still available thanks to Google Books. His writings have come very useful in writing this history of difficult breathing.

References:

1. "Dr. Samuel Jones Gee", Historic Hospital Admission Records Project,  http://hharp.org/library/gosh/doctors/samuel-jones-gee.html, accessed 8/21/14
2.  Dowd, Brian, John Walker Smith, "Samuel Gee, Areteaus, and the Coeliac Affection," 1974, British Medical Journal, April 6, page 45
3.  Gee, Samuel, "Bronchitis, Pulmonary Emphysema, and Asthma,", Lancet, March 25, 1899, page 817
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1837: The botanic asthma remedy of Carter and/or Mathes

It is the year 1837, Andrew Jackson is president, you live on the frontier, and you are suffering from a fit of asthma.  What do you do to treat your difficult breathing?

Well, for one thing, you could grin and bear it and wait for nature to bring your breath back.  But there are too many uncertainties with this route, such as: how long can you suffer like this? What if your breath doesn't come back, then what?

Another option would be to find a doctor at some nearby village, which was highly unlikely.  Besides, what if the long ride there made your asthma worse and there wasn't a doctor, then what?

There was another option, one you might have read about in a local paper, and that was to seek the help of a root and herb doctor, which was in its hey day during the Jackson Presidency.

You certainly heard about Samuel Thomson and his army of root and herb doctors plastered across the nation.  Would there be one of these in the nearest village? It wasn't worth the risk to find out.

A fourth option might be your best bet, and this was to have in your possession a book of root and herb remedies written by a root and herb doctor.  You just happened to have on your desk such a book by J.E. Carter, and A.H. Mathe called, "The botanic physician."

The book contained every thing you needed to know about root and herb medicine, botanic medicine, folk medicine, Indian medicine, herb Medicine, stick medicine, or whatever you wanted to call it.  You read about the book a while back in some random newspaper you read, and you purchased a copy at some random general store.

You read some nasty things about these sorts of doctors, that they were copycats, quacks, or otherwise pent on peddling their fake products, most of which contained just alcohol, just to make a buck.  But you weren't concerned about that, especially while you were sitting in your log cabin, miles from any village, struggling to breathe.

Your best hope was that Carter and Mathe were among the few honest root and herb doctors hoping to help their fellows.

You open the book to a page you had marked, sneezing and sniffling as you do so.  You read the passages you were looking for.

ASTHMA OR PHTHISIC.

This complaint is a spasmodic affection of the lungs, which mostly comes on by paroxysms or fits. It is attended with a short, difficult, frequent respiration, with a peculiar wheezing; there is also a stricture or tightness across the breast, which produces a peculiarly unpleasant sensation. Some have so light an attack of this disease, that they experience but little difficulty from it except when they take cold. Others are never entirely clear of its symptoms. Those who are afflicted with this complaint, experience an increase of the symptoms in the evening, and during the early part of the night. Towards morning the symptoms suffer some abatement-; sometimes enough to let the patient get some sleep, but the patient cannot lie down, without increasing the difficulty of breathing, and suffering a sensation similar to suffocation. This complaint is so easily known, that we deem it unnecessary to add any thing more on the symptoms.

TREATMENT

This distressing complaint has long been numbered with those that could only be mitigated, and not cured; but the introduction of the botanic practice has stripped this disorder of its wheezing terrors, and offered the afflicted asthmatic a relief from this suffocating torture. In the whole compass of medicine there are but two articles yet discovered, that are very useful in this complaint, or deserve any thing like the character of being specifics for it; and these are botanic remedies.

The tincture of lobelia, given in doses of a tea-spoonful twice a day, or the pulverized lobelia given in doses of from half to a whole tea-spoonful, once a day, has been found almost a specific for this disorder. In some eases, the pulverized root of skunk cabbage, administered in doses of a half or a whole tea-spoonful mixed with honey or melasses, and repeated as the symptoms may require, often gives relief, in some kinds of asthma when the tincture does not effect a cure. It acts both as arc expectorant, and anti-spasmodic, which gives it a peculiar advantage in some cases of this complaint; yet in most cases, the tincture of lobelia is the surest remedy. In severe cases of long standing, it will be necessary in addition to the above, to carry the patient through several courses of medicine, at least one a week until a cure is effected. It will be necessary for the patient to make a daily use of some diaphoretic tea during the whole time he is using other remedies. He will facilitate the restoration of health and vigor, by using the astringent and bitter laxative tonic powders; and if his bowels ire incline to be costive, give him the stimulating tonic clyster occasionally to keep them regular.

Next to the book are the boxes containing the ingredients.  You prepare them, ingest, and wait.

What would it be like to have asthma on the American Frontier in 1837?" Sometimes it's good just to let our imaginations run wild.

References:

1. Carter, J.E., A.H. Mathes, "The botanic physician, or family medical adviser:  being an improved system, founded on correct physiological principles comprising a brief view of anatomy, physiology, pathology, hygiene, or art of preserving health: a materia medica, exclusively botanical, containing a description of more than two hundred and thirty of the most valuable vegetable remedies: to which is added a dispensary, embracing more than two hundred recipes for preparing and administering medicine.  The diseases of the United States with their symptoms, causes, cures, and means of prevention.  Likewise, a treaties on the diseased peculiar to women and children," 1837, Madisonville, Tennessee, Published by B. Parker and Company

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1835: Ramadge's inhaling tube for consumption and asthma

Figure 1 -- Ramadge Iinhaling Pipe (1, page 93)

Respiratory therapists are well aware of insentive spirometers (IS) and positive end expiratory (PEP) therapy. You might think these are modern inventnions. You would be wrong.

Incentive Spirometers are small, hand held devices that that encourage patients who are on pain medicine, or who had recent abdominal or chest surgery, to take deep breath and cough to facilitate movement of secretions, thereby preventing or treating atelectasis and pneumonia. The incentive spirometer was invented in 1970 by R.H. Bartlett and quickly became an inexpensive mode of bedside therapy.

PEP therapy involves having the patient blow through a resistor that applies resistance, or positive pressure (usually 10-20 cwp), during expiration. The pressure acts as a splint to keep otherwise collapsible terminal airways and alveoli open. This facilitates the movement of secretions that would otherwise be trapped due to airway closure. It was invented in Denmark during the 1970s and was became popular in Scandanavia, Denmark and Canada before making its way to the United States. (5, page 1001)

So both IS and PEP therapy were invented during the 1970s and are forms of chest physiotherapy, or chest exercise through manual movement. However, the general concept was conceived of back in 1810 by a doctor by the name of Francis Ramadge.

He was a student of Rene Laennec, the inventor of the stethoscope.  The two men worked together in order to find a means of preventing people from developing consumption, the most common respiratory disease at that time.

Laennec suggested a natural cure for consumption was the formation of cicatrizations, or scar tissue, following the softening of the tubercles.  This scar tissue, he suspected, acted as a natural barrier against the disease. He suspected most people living with the disease had such scar tissue.

Ramadge, on the other hand, believed that since consumption resulted in a small, contracted and frail rib cage, anything causing the opposite effect prevented consumption. Various other physicians agreed with Ramadge. (1, pages 91- 93)  (3, page 8-9, 37)

Two such diseases suspected as acting as natural barriers against the disease, Ramadge suspected, were catarrh (colds) and asthma. He said:

For instance, let us begin with catarrh. Here tumefaction (swelling) of the mucous membrane preventing the free egress of the air, imprisons it in the air-cells, and produces a quasi emphysematous state of the lungs, expanding their entire volume to a certain degree, and pushing outwards in every direction the walls of the chest. Asthma also acts in a similar way. (3, page 8)

They believed if patients took care of their asthma this would act as a barrier to consumption. Ramadge said that this was one of the "ulterior good" effects of having asthma. It was "a lesser evil being substituted for a greater." (6, page 37)(1, pages 91- 93) (3, page 9, 37)

Ramadge also believed that any medical condition that impeded free expiration tended to "mitigate and arrest the disease."  Such conditions included: enlarged tonsils, tumors pointing towards the pharynx, polyps in the nasal passages, aneurysms of the aorta, diseases of the heart, obstruction of the liver, hysteria and pregnancy.  (3, page 8)

It was based on these theories that he invented what was called "an inhaling pipe," which would later be referred to as the Ramadge Inhaling Pipe.  He believed that by inhaling and exhaling through the pipe the patient would develop an expanded chest. In this way, regular use of the pipe had "palliatve and prophylactic, as well as a curative, intentions." (1, page 93) (3, page 10, 59)

It was a pipe with hot tar stuffed into it that you inhaled for therapeutic means. The tar, and the narrow diameter of the tube, provided resistance to inspiration and expiration, and this was supposed to provide "gymnastics" or "exercise" for the consumptive patients.

The Ramadge Inhaling Pipe wasn't exactly PEP therapy, but the principle was similar.  He said:

The value of the tube in catarrh, which it supersedes as a curative agent, must not be overlooked. By due exercise and expansion of the bronchial ramifications, it contributes to allay, or indispose to, irritability of the lining membrane, and I have often heard patients state that after its use in the morning they have been better, and more freely able to bring up the accumulated phlegm. (3, page 59)

The inhaling pipe wasn't an IS, although it worked similarly to encourage deep breathing and coughing.

Ramadge said:

The lungs may simply and safely be kept in daily exercise, and expansion to the full amount may be effected by atmospheric inhalation, through the respiratory apparatus. (3, page 15)

Dr. Samuel Sheldon Fitch, in his 1847 book "Six lectures on the uses of the lungs," described the tube.  He said: (1, page 91-93)

This tube he at first made about four and a half feet long, with an opening through its whole length, provided with a mouth-piece to go between the lips, and the patient sucked in, or inhaled the air as long as he could, and then through the same tube, blew it out again. By this process, the chest would rapidly enlarge. Dr. Eamadge also made an inhaling tube a little like a whistle, with a valve in it so constructed that the air would go into the mouth and lungs through a large free passage, and on returning, the air would be forced to go outmof the mouth and lungs through a much smaller opening. The effect of which is, to allow the lungs to fill rapidly and without exhaustion of strength, and on leaving the lungs, it is all passed through an opening not much larger than a knitting- needle, by which the air was slowly forced out of the lungs, and by this pressure the lungs were greatly expanded, and the air every where opened the chest in the largest manner. (1, page 93)

Fitch said the tubes were made of wood or ivory, although he recommended they be made of gold, platina or silver so that they last long, and the patient can take the tube wherever he goes and can use it often to keep his lungs expanded.  (1,2)

Ramadge said he'd prefer his patients use the inhaling tube...

...but, in the absence of the inhaler, I have no hesitation in saying, on the Principle of choosing the minor of two evils, that exposure to the exciting causes of catarrh, under prudent restrictions, is an alternative that may be judiciously adopted in consumption. (3, page 15)

Surely there were other remedies for consumption, such as leeches, tonics, sedatives and relocation, but...

...The use of the inhaling tube I consider to be essential in the treatment of phthisis; indeed, all other treatment is comparatively secondary and ancillary. (3, page 10)

He said it worked even as a last ditch effort to save the life of a consmptive in the dire states of the disease.  He said:

It may be thrown out as a sheet-anchor, even at the eleventh hour. A clergyman's daughter, who had been despaired of, in phthisis, by several medical men, was induced, as a dernier ressort,to employ the inhaling apparatus for two or three months, during which period a decided retrogression of all her bad symptoms was established. Considering herself well, she left it off and died. It is not improbable that, had she gone on till her disease had been more completely brought. (3, page 59) 

While recommended for consumptive patients, he said his inhaling device also worked well for asthmatics.  He said:

In asthma the windpipe is too small for the volume of the lungs, and, though it may seem contradictory, the mechanical respiration by the tube has the effect of restoring this disturbed relation to its healthy standard. The objection to it, on the score that asthma is liable to be superinduced by its use, arises from idle prejudice. Could I but present one-tenth part of the cases which have been rescued from a premature grave, chiefly by means of using this instrument, I should force irresistible conviction on the most incredulous, or at least induce them to institute a number of experiments, patiently and judiciously, so as to satisfy themselves of the truth. (2, page 10)

Not sold yet as to the efficacy of the Ramadge inhalaing pipe?  Well, how about some endorsements that might change your mind.  Ramadge said:

This mode of treatment has many advocates, both in England and abroad. Lebeau, physician to the King of the Belgians, and senior surgeon of the Military Hospital at Brussels, as also Hohnbaum, physician to the Duke of Saxe Meiningen, and a distinguished pathologist, highly approve of it. Among the American medical men might be mentioned, the names of Drs. Pitch, Newton, and Hull, of Philadelphia, and several other distinguished practitioners of the same country, together with a great many continental physicians, all of whom have adopted its use, and are its zealous supporters. (3, page 11) 

Ramadge would go on to become a well respected physician who specialized in pulmonary disease, ultimately becoming senior physician to the Infirmary for Asthma, Consumption, and other diseases of the Lungs. He claimed to have had the advantage of over 30,000 cases of consumption in all its various stages. He said:

I have no hesitation in asserting -- in contradiction to the opinion of many medical practitioners -- that this disease when properly, judiciously, and skillfully treated, is a curable as any other disease, the curability of which is not dispute. (1, page iv)

The Ramadge Tube was recommended by physicians for pulmonary gymnastics and as a prophylactic therapy for consumption until better devices were invented at the turn of the next century. (4, page 228)

Further reading:

• 1819: Laennec says consumption can be cured
• 1910: Early PEP and Incentive Spirometers

References:

1. Fitch, Samuel Sheldon, "Six lectures on the uses of the lungs," 1847, New York, H. Carlisle, pages 91-93, 
2. Laennec, Rene, "On Mediate Auscultation," 1827, London, T and G Underwood.  
3. Ramadge, Francis Hopkins, "The Curability of Consumption: the reprint of a series of papers, presenting its most prominent and important practical points in the diagnosis, prognosis, and treatment of the disease," 1850, London, Printed by W. Clowes and Sons
4. Tissier,Paul Lewis Alexandre, edited by Solomon Solis Cohen, "Pneumotherapy: Including Aerotherapy and inhalation methods," volume X, 1903, Philadelphia, P. Blakiston's Sons and Co., pages 227-230.  If the profession of respiratory therapy existed in their era, we would be reading their books.  However, as it was, their books were written for the medical profession.  For a more detailed description of any of the devices mentioned on this blog click on the links provided. Unless otherwise indicated, all material from this post was from Tissier's book. 
5. Sehlin, et al, "Physiological Responses to Positive Expiratory Pressure Breathing:A Comparison of the PEP Bottle and the PEP Mask,"  Respiratory Care, August, 2007, Vol. 52, No. 8, pages 1000-1005

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1835: Ramadge renews interest in nervous asthma

A fit of asthma is like the suffocation caused by a noose.
Francis Ramadge said: "As the respiration becomes more 
difficult the pain at the chest increases, and the constriction
is at last so intense as to be compared by the sufferer,
to what might be supposed to arise from cords bound tightly
 around it. It heaves and dilates as if striving to burst these
 imaginary bonds, and is again compressed, as it were,
by their violent re-action.. after retiring early to bed...
the patient is suddenly awakened in a few hours 
by a feeling of strangulation, and finds that the fit has
seized him with all its violence. When fully awake,
 he finds an oppression of the chest, weighing him down 
like an incubus, and is constrained to sit up, 
or to quit his bed at once, if, as he imagines, 
he would escape suffocation." (6, page 43, 45)

By the end of the 18th century nervous asthma had gone out of fashion, becoming once again merely a form of dyspnea or a symptom of some other disease, such as bronchitis.   The idea that asthma was nervous in origin was not revived until the writings of Dr. Francis Hopkins Ramadge in 1835.  (1, page 599)

Ramadge was born in 1793 in Dublin, and was educated at Dublin college in London.  He received his bachelor's degree in 1816 and a master's degree in 1819 at Dublin.  He earned his medical degree at Oxford in 1821.  (3)

He was a student of Rene Laennec, the inventor of the stethoscope.  So he would have been well acclimated to this new tool.

He went on to become a well established physician in London, developing an "extensive" and "lucrative' practice that focused "chiefly" on diseases of the chest. (7, page 92)

He became senior physician to the Royal Infirmary for asthma, consumption, and other diseases of the lungs.  He as lecturer on the principles and practice of medicine and chemistry.  (3) (6, page iv, 64)

Ramadge published a book on consumption that was well received, and this inspired him to write a book on asthma called"Asthma, its species and complications, " which was published in 1835.  (6, page v)

He wrote that asthma was "less fatal (than consumption), it is true; but, when of an aggravated character, as exquisitely painful to the sufferer, as it is alarming to the beholder." (6, page v)

He said his book on asthma was necessary because...

...little has yet been done to put either the pathology, or the therapeutics of Asthma on a satisfactory basis. The few works of our English medical writers on the subject propose little beyond theory in the one, and palliation in the other. Nor have the labours of the continental physicians been much more successful. The views put forward, in this country at least, have been chiefly traced from the limited opportunities of private practice, for the most extensive are circumscribed, when compared with those afforded by a public institution. (6, page v-vi)

Of asthma, he observed what we already know:

Its Greek etymology (difficult respiration) is so comprehensive in its signification, that numerous disorders, distinctly separated from each other by their causes, and differing in their effects, have been classed under the name of Asthma, as a generic term, from then. agreeing in one general character—difficulty of breathing. This has not only produced much confusion among medical writers, but, as a necessary consequence, has led to a similar result in practice.

These are important statements made by Ramadge, because they show, as a pioneering physician of the scientific era, how vigilant he was of the theoretical basis of most conclusions regarding asthma prior to his era, and even during his era.

So he aimed to end this confusion, and he aimed to do it by using the one advantage he had over them: the stethoscope.

By using this new tool he was able to prove that bronchitis followed and did not precede a fit of asthma, and this, he believed, should disprove the bronchitis and humoral theories of asthma that postulated it was the result of inflammation and secretions in the lungs caused by organic lesions or, as Robert Bree speculated, some peccant matter that made its way into the lungs.

He did not deny asthma was humoral, yet he believed organic lesions were more likely to cause asthma in the extremes of life, such as in childhood from congenital abnormalities, and in adulthood from lesions of the large vessels and heart.  He said humoral asthma, when it did occur, was most likely in old age. (6, pages 9-10)

By using his stethoscope, he believed the following should not be considered forms of asthma, but disease entities of their own.  (6, page 10)

• Structural impediment of the larynx that narrow the airway (6, page 10,33)
• Structural impediments of the trachea that narrow the airway (6, page 10,33)
• Extensive adhesion (6, page 10)
• Emphysema of the lungs  (6, pages 10, 35-36)
• Bronchitis, dyspnea with inflammation (6, pages 10,33)
• Hydrothorax, edema of the lungs  (6, page 10)
• Glandular or calcareous obstructions at the root of the lungs  (6, page 10)
• Various organic lesions of the heart or aorta  (6, page 10)
• Valvular irregularity of the heart or aorta  (6, page 10)
• Ossification of the coronary arteries  (6, page 10)
• Chronic pericarditis, (6, page 10)
• Angina Pectoris, Darwin's asthma, Laennec's Neuralgia, chest pain, cardiac asthma (6, pages 18-33)
• Pulmonary apoplexy (6, page 34)
• Acute Catarrh, swelling of the air passages, nasal passages, etc. 
• Etc. (6, page 10)

He believed that all of these could be distinguished from asthma simply by means of auscultation with a stethoscope and thorough assessment and questioning of the patient.  For example, when a patient complains of chest pain, or is yelling things like "My arm!  Oh, my arm!" a physician might think angina, not asthma, is the cause of the person's agony.  (6, pages 18-19)

He did, however, believe that any of these may lead to asthma.  He also beleived that asthma, when "long continued" may result in organic lesions that seriously affect a person later in life.   (6, page 36)

So, instead of thinking that asthma was humoral or bronchitic in nature, and in the absence of organic lesions, Ramadge postulated that asthma must be nervous in origin.

In order to allay some of the confusion regarding the term asthma, he decided that he needed to come up with a new term.  He therefore decided that nervous asthma was asthma in its pure form, was nervous or spasmotic or convulsive or idiopathic asthma.  Yet he preferred to refer to it as pure or essential asthma.  (6, pages 65-66, 92)

He believed a paroxysm of asthma occurred when some exciting cause, either internal or external, irritated the nerves, resulting in the brain sending messages along nerves supplying airway and pulmonary tissue, including the bronchi.  This message causes spasms of the trachea and bronchial tubes. (4, page 3)(5, page 193)(6, page 12)

He believed that essential asthma was caused by "some injury done to the nerves of the chest, by cold or other means.  He described a case of asthma that he suspected arose after a case of the hooping cough.  When this happens, the pneumogastric nerve, which supplies nerves to the throat and lungs, becomes damaged or irritated. (4, page 60-61)

Other exciting causes might include: 

• Troubled mind or passions of the mind(6, page 19, 59)
• Passions of the mind (such as fear, excitement)(6, page 86)
• Irritable temperament (6, page 59)
• Gusts of passion (6, page 19)
• Excessive eating (6, page 11)
• Excessive drinking (6, page 11)
• Excessive anything (6, page 11)
• Inhalation of occupational particles, metals, or dust (6, page 11)
• Nervous temperament (6, page 11)
• External irritants, such as strong smells like the smell of tea (5, page 193)(6, page 11)
• Internal irritants, such as a visceral (organ) irritation, sympathetically affecting the brain, or a tumor in the lungs, or adhesions in the lungs.  (6, page 11)
• Atmospheric influences, such as changes in weather; excessive heat at end of May, or  (6, pages 14-16)
• Particular period of the year, such as winter or summer (this would be the most common in the purely nervous asthma; the most violent asthma occurs after the summer solstices) (6, page 46)
• Stomach ailments (caused by food ingested, indigestion, dyspepsis, etc.)(6, page 83, 86)

He said pure or essential asthma caused morbidity, but did not, as a general rule, cause mortality.  He said:

The prognosis of asthma is seldom difficult.  Doubt can arise only in cases severely complicated. When asthma wears the purely nervous form, danger is rarely to be apprehended." (6, page 36)

However, he added:

"To sum up prognosis in a few words, asthma is seldom productive of present danger, but often betokens much future inconvenience."

He believed asthma was periodic, the episodes were generally short lived, and the intervals in between the fits were of varying lengths.  He also believed the person would experience perfect health between episodes. (6, page 17)

It was only when asthma was prolonged, or continued for a long time, that it might cause organic lesions resulting in such conditions as emphysema of the lungs, bronchitis, heart disease, or other diseases often confused as asthma.

Symptoms of essential asthma were: (6, page 45)

• Difficulty in breathing (6, page 18)
• A sense of suffocation (6, page 18, 43)
• Pain across chest (6, page 43)
• Flatulent uneasiness in the stomach and bowels (6, page 16, 46)
• Undefined oppression and constriction of the chest (6, page 16)
• Dry cough (6, page 16, 43)
• General irritability (6, page 16)
• General impatience (6, page 16)
• Headache (6, page 16)
• Dejection (6, page 16)
• Langour (6, page 16)
• Thirst and dryness of the mouth (6, page 17, 43)
• Dry and cold skin (6, page 17, 43)
• Copious flow of clear urine (6, page 17, 45)
• Drowsy (6, page 42)
• Disinclined to exertion (6, page 42)
• Apt to fall into disturbed and uneasy slumber (6, page 42)
• Wheezing on expiration (6, page 43)
• Wheezing accompanies exertion, and is audible (6, page 43)
• The sufferer literally gasps for breath (6, page 43)

Similar to those who support the humoral or bronchitic theory of asthma, such as Bree, Ramadge believed the fit of asthma usually ended with the expectoration of sputum. (6, page 17, 46)

He believed that pure asthma was a rare condition.  (6, page 103) 

He even speculated as to which folks were most likely to acquire disease:

The predisposition to asthma is very generally apparent, in individuals of a defective constitution, and morbid temperament. In numerous instances, it may be traced to the transmission of the nervous susceptibility of receiving impressions, injurious to the respiratory functions, from parent to child. How frequently indeed do we see a kind of general disposition handed down, from one generation to another; sometimes immediately, at others with the intermission of one, or more generations. And we frequently find that the more intimate the moral, no less than the physical organization of two individuals, the one in the ascending, the other in the descending line; the more probable is it, that the latter will inherit the morbid peculiarities of the former. (6, pages 101-102)

He suspected asthma to be be hereditary.  He said he observed its occurrence in n four generations of one family.  He said the father had asthma, and three of his four children also had asthma. He said one of the daughters married, and, of her two children, one had asthma. The one who had asthma also had a child with asthma.  (5, page 190)(6, pages 56, 101-102, 104)

Ramadge wondered why the nervous theory of asthma fell out of favor among the medical community.  He blamed it on the fact that...

...from the time of Willis, who was the first to observe the nervous character of uncomplicated asthma, down to the publications of Laennec and Andral, no light has been thrown on the seemingly inexplicable disease from morbid anatomy.  All agree that it is impossible to discover any lesion; or from post-mortem examination to assign any cause for the presence of the disease. (1, page 92)

He added:

It is deeply to be regretted that our own writers on this disease should not have been more anxious to investigate its pathology, than their works would evidence. From many circumstances in cases detailed by them, I am induced to believe that many important states have been either overlooked, or misunderstood. Had due attention been given to the subject from Willis's time to the present, we should have had a rich harvest of facts on which to reason. As it is, we are presented with innumerable details, gleaned from the works of men who wrote at a period, when the art of minute dissection was in its infancy; and when, consequently, many appearances of consequence to a full understanding of the case must have escaped notice. (1, page 96)

Despite this work by Ramadge, it wasn't until 1851, through the prize winning work of Bergson and Lefevre , that nervous theory of asthma would be fully accepted by the medical community, and that asthma would be "recognized as an independent affection."  (1, page 599)(2, page 596)

He died 31 years later in 1867. (3)

References: 

1. West, Samuel Hatch, "Diseases of the organs of respiration," volume II, 1902, London, Charles Griffin & Company, Limited 
2. Whitaker, James Thomas, "The theory and practice of medicine," 1893, New York, William Wood and Company
3. Gordon, Goodwin, "Ramadge, Francis Hopkins," from the "Oxford Dictionary of National Biography: 1885-1900," volume 47, Matthew, H.C.G., Brian Harrison, Lawrence Goldman, editors, http://en.wikisource.org/wiki/Ramadge,_Francis_Hopkins_(DNB00), accessed 2/10/14
4. Schmiegelow, Ernest, "Asthma, considered specially in relation to nasal disease," 1890, London, H. K. Lewis
5. 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.
6. 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, Orge, Brown, Green, and Longman
7. Fitch, Samuel Sheldon, "Six lectures on the uses of the lungs," 1847, New York, H. Carlisle, pages 91-93, 

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1835: Ramadge questions that Dr. Bree had asthma?

So we know that Dr. Robert Bree published a book called "A Practical Inquiry into Disordered Respiration" that became the principle authority on asthma during the first half of the 19th century. Yet his book did not come without criticism.  

George Lipscomb, a fellow British physician, had the nerve to criticize Dr. Bree's ideas regarding asthma even as the book was first published.

Then, in 1935, Dr. Francis Hopkins Ramadge, in his 1835 book "Asthma, its species and complications," went almost as far as to suggest that Dr. Bree did not have asthma at all, and, therefore, was probably describing some other disease.  

He said: 

Dr. Bree delineated the early stages of his disorder, as distinctly as the latter, I have no doubt it would be found, that his asthma supervened upon latent consumption. Thus he gives no account of the symptoms preceding dyspepsia, which would have indicated, at once, the origin of his complaint. But, it is evident that some ailment of the chest was early at work, from his alluding to pain of the intercostal muscles, which could hardly have existed without; or, the reverse might have happened, and the dyspepsia impairing his health, have thus indirectly originated the pulmonary affection. (1, pages 135-136)

Some remarks of Laennec coincide wonderfully with this view of the case. He observes, "that nervous symptoms may mask phthisis for a long period; and that he has known it concealed for years by habitual dyspepsia, and other symptoms of hypochondria." (1, page 136)

This, in fact, is giving in other words the commencement of Dr. Bree's case, as stated by himself. So strongly, indeed, am I convinced that one or other of these explanations will apply to the learned Doctor's case, and elucidate what has been omitted by him, that, could he be induced to summon up his recollections, and retrace minutely the precursory symptoms of his disease, it would, I have little doubt, appear that either before, or during his dyspeptic condition, he had had attacks, slight ones perhaps, of haemoptysis. However, for an author to retrace his steps, crossexamine himself, and confess his views to be erroneous, would be an effort of candour above the powers of poor humanity! (1, pages 136-137)

I would not be supposed to insinuate, that any thing was purposely omitted by him. On the contrary, I believe he has detailed, and fully too, every symptom he conceived to be of importance; and that, supposing he had laboured under slight spitting of blood, he would have deemed it too irrelevant for notice. The course, therefore, of his complaint, on the supposition of the correctness of the views above taken, would be that on the appearance of the dry form of asthma, which did not exhibit itself for several years after the first manifestation of dyspnoea, his lungs became emphysematous, and the cavity, which I conjecture to have previously existed, was gradually healed up. The care he appears subsequently to have taken of himself put a stop to the bronchial affection, and with it of the asthma,which at one period seems to have been habitual with him. (1, pages 137-138)

Dr. Ramadge, along with other physicians who came to the same conclusion about Dr. Brees ideas regarding asthma, said that Dr. Bree was a smart man who, if he had had access to the stethoscope of Dr. Rene Laennec, would have easily seen his mistake.  

About twenty years later Dr. Henry Hyde Salter, who we will come to know as the author of the most famous asthma book of the second half of the 19th century, also criticized Dr. Brees ideas regarding asthma. 

Dr. Bree argued in favor of the bronchitic theory of asthma.  He believed the spasms or convulsions associated with a fit of asthma are all a part of the bodies effort to get rid of some irritating or peccant matter that was inhaled into the air tubes.  

I know I quote Dr. Salter's criticism of Dr .Bree in another post, yet I think it's worth repeating here.  Dr. Salter said: 

Dr. Bree maintains his argument with a great deal of ingenuity, and presses many facts into the service of his theory; but the most superficial reflection would suffice nowadays to show that it is utterly untenable ; and had Dr. Bree enjoyed the light that now shines on us from those two important points, the stethoscope and our acquaintance with excito-motory action, he would never have broached the doctrine he did: the one would have shown him the fallacy of his views, the other would have opened to him a solution of his difficulty—the stethoscope would have shown him that the conditions of an extraordinary discharging power are not present in an asthmatic attack ; indeed, that the power of getting rid of anything in the lungs is very much diminished by it; and the knowledge of reflex nervous action would, in connection with anatomy, have displayed the true nature of the disease, and made all its discrepant and scattered phenomena conspire to the production of its true and simple theory. (2, page 5)

With all due respect to Dr. Bree, the same argument about "if he had access to the stethoscope" could have been made regarding any of the physicians who studied lung diseases during their careers.  

Still, the argument that Dr. Bree never had asthma at all, and that his book did not describe convulsive asthma but some other disorder of the lungs, was quite impelling.  

References: 

1. 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
2. Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment," 1882, New York, William Wood & Company; Dr. Salter's book was originally published in 1860, and was previously released as a series of articles during the course of the 1850s

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