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 convulsivum. The 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

1854: M. Priory fine tunes stethoscope and percussion

Pierre Adolph Priory (1794-1879)

Joseph Auenbrugger, Jean Corvisart, and Rene Laennec introduced the medical community to chest percussion and auscultation.  Both techniques became valuable for helping physicians diagnose diseases of the chest, although both needed to be perfected.  

By the time of his death in 1826, Rene Laennec saw his invention of the stethoscope become accepted by his peers.  However, he would readily admit that his new tool was not yet perfected. He would spend many hours himself improving upon it, and when he died this task was left to his peers.

Pierre Adolph Piorry (often referred to as M. Priory due to his French origin) was born in 1794, served in the Napoleanic wars in Spain, and served at the Atarazanas Hospital in Spain where he was able to witness military surgery." (1, page 675)

In 1814 he returned to his medical practice in France, and, like Laennec, served as a student of Corvisart. He qualified as a physician in 1816, the same year Laennec invented his stethoscope.  (1, page 675)

This is a picture of the Priory binaural stethoscope complete with
the pleximeter(round, solid ivory disks on bottom second from left)
and fingerthimble ivory percussor (on botton right).  Picture from 1828.
Photo from http://www.antiquemed.com/binaural_stethoscope.htm

He had a gift as a teacher, and between 1817 and 1826 he delivered lectures on physiology and pathology.  In 1826 he was appointed physician to the Paris Hospital.  In 1837, after many years of attempting to do so, he became professor of medicine at Paris School of Medicine (l'Hospital de la Pitie, Paris).  He was 43.  (1, page 676)

He then took off where Laennec left off, working hard to fine tune the binaural stethoscope.  The product he ended up with would be the general design of most stethoscopes used for the rest of the 19th century.  He also worked to improve the technique of percussion.  His work in this area created excitement for the remainder of the century, although it would ultimately be for naught. (1, page 675)

A Classic Reprint Series of Priory's book
is proof his ideas are still sought after.
The first edition was published in 1826.

His stethoscope was trumpet shaped and made of wood, although it was shorter and thinner than Laennec's.  It came with a removable wood plug, ivory earpiece and chest piece, with the chest piece also serving as a pleximeter (described below).  This design was also much more pleasing to physicians, and was much easier to carry in their bags. (5)

In a 1979 Biography of Priory, Alex Sakula said of Priory:

Priory, enthused by Laennec's invention, developed an ambition to emulate the great master and to achieve fame in some similar fashion. Priory describes in his poem Dieu L'ame et Nature how he came to study percussion.  He prayed to God asking to be able to make some discovery like that of Laennec.  A few months later, he had slight pruritus and while scratching the skin over his chest he heard a sound.  He interposed a coin and scraped it and obtained a stronger sound, which varied according to the density and elasticity of the underlying organ." (1, page 577)

This is a picture of Priory's Pleximeter. (5, page 311)

Sakula said that the next day he began his work on percussion, and hoped that what Laennec had done for auscultation he could do for percussion.  On February 28, 1826, he "read a prize winning paper on his new method of percussion to the Academie Royale de Medecine.  Laennec (then very near his death) was one of those present." (1, page 577)

Scott Alison, in his 1861 book, "The physical examination of the

 chest," described the procedure of percussion as follows: 

 The pleximeter is to be placed in or over an intercostal space,

 or upon a flat surface, and fitted well with gentle pressure upon

 the body,and held by the thumb and forefinger of the left hand. 

It may be employed together with a hammer or with the fingers." 

A percussion hammer is sown here.  (5, page 311

In the paper, Sakula said, Priory described his new technique of doing percussion, which involved placing a small plate between the patient's skin and the percussing finger.  He called the plate a pleximeter from the Greek words to strike and to measure. (1, page 577)

This little gadget shows the extent that some physicians went to 

create the perfect pleximeter.  Scott Alison described it as:

"An instrument combining both a pleximeter and a hammer 

was contrived by Dr. Aldis some years ago. It consistsof a

 hammer moving on a fulcrum, and of a disc of cork which 

receives the blow of the hammer. The cork disc is placed 

upon the chest, and the hammer is raised by the finger to the

 required height. The higher the hammer is raised, the more force

 is obtained. The hammer falls by the operation of a spring.

 Great uniformity of blow is obtained by this instrument. 

This ingenious contrivance has obtained the name of 

echometer." (5, page 312)

As Laennec experimented with various materials while trying to perfect his stethoscope, Priory experimented with various materials while trying to perfect his pleximeter, said Priory, "but finally settled on a small ivory plate, 5 cm in diameter.  He also devised a combined stethoscope and pleximeter made of ivory and cedar wood." (1, page 577)

These are a few of the varieties of wooden binaural stethoscopes
in use by physicians as of 1861. (5, page 316)

After all the publicity that the stethoscope had garnished since Laennec introduced it in 1819, percussion had lost some of its luster.  Some probably believed the stethoscope would replace it completely.  (1, pages 576-577)

However, Sakula said:

"Piorry did not regard percussion as competing with auscultation, and taught that the two techniques were supplementary one to another." (1, page 577)

This is a flexible stethoscope.  In his 1861 book, Scott Alison said,
"In employing the flexible stethoscope, it is even more necessary
than in the case of the wooden instrument to observe that the object
end is well applied so as to close the tube.  If left partially open,
scarcely any sound is perceived. (5, page 321)

There were still many physicians who did not adapt his stethoscope and pleximeter.  Many who finally accepted his research on percussion came up with their own techniques for performing the procedure.  For instance, the preferred method became the use of the finger of one hand used as the pleximeter, and the finger of the other hand as the percussor.  Yet the principle is the same.  (1, page 577)

The Cyclopaedia of Practical medicine, edited in part by John Forbes, best concludes the accomplishments of Priory regarding percussion: (3, page 7)

M. Priory, a young Parisian physician, has the honor of having, if not invented, at least brought into a formal and matured shape, this new application of the discovery of Auenbrugger, and with practical results greater precision and importance than could have been anticipated. (3, page 7)

Dr. Sibson's pleximeter 

consists of a plate of 

ivory which receives

the blow, and of a brass

hammer or weight

working in a metal frame.

. The weight or hammer

is raised by the fingers;

these being removed, 

the weight or hammer 

falls upon the ivory plate

by the elasticity of an

indiarubber band connecting 

the weight or hammer 

with the ivory plate.

The hammer works

perpendicularly

to the plate. (5, page 313

Like many new tools invented or discovered to assist physicians do their jobs better, the Priory stethoscope and pleximeter were not accepted by all physicians.

Piorry remained a famous physician until his retirement at the age of 72 in 1866.  He died at age 85 in 1879.

Yet long before he passed from this world his hard work paid off.  By 1854 percussion had been fine tuned so that it was often performed not just over the chest, but over various organs of the body to help doctors diagnose any pathological disorders.

While there were various stethoscopes designed during the remainder of the 19th century after Priorry's death, most were adaptations of his design.  Examples include binaural stethoscopes made by Quain, Stokes, Arnold, Barclay, Elliotson, Dobell, Loomis, Burrow, Clark, Camman, and Furguson. (4, page 626)

These other stethoscopes were made of various materials, produced by various manufacturers, and were scattered through various publications.  Still, Priory's stethoscope remained the most popular design for the remainder of the century.

References:  

1. Sakula, Alex., "Pierre Adolphe Piorry (1794-1879): pioneer of percussion and pleximetry," October, 1979, Thorax ( 34(5): 575–581).  
2. "The Binaural Stethoscope," antiquemed.com, http://www.antiquemed.com/binaural_stethoscope.htm, information reviewed March 8, 2012
3. Forbes, John, Alexander Weedie, Conolly, editors, "The cyclopaedia of practical medicine," volume 1, London, 1833
4. Camman, Donald M, "Historical Sketch: Stethoscopes," A Reference Handbook for Medical Sciences, edited by Albert Henry Buck, by various writers, volume VI, 1888, New York, William Wood and Company, 626-628
5. Alison, Somerville Scott, "The physical examination of the chest in pulmonary consumption and its intercurrent diseases," 1861, London, John Churchill

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1840: Dr. Williams proves spasmotic theory of asthma

Charles J. B. Williams (1805-1889)

Healthcare workers may recognize the name Dr. Charles James Blasius Williams because he was the first person to use the terms "lub-dub" to describe the sounds emitted by the two chambers of the beating heart.  This is what history best remembers him for.

While this fact is definitely important to our history, what we are mostly interested in is the fact that Dr. Williams was the first person to effectively prove the spasmotic theory of asthma by discovering that the muscular fibers that wrap around the air passages may spasm under certain conditions.

According to his own memoirs, Williams was the youngest of nine siblings. His mother was the eldest daughter of a respected surgeon, whose name was also Williams. She died shortly before her son Charles started college at Edinburgh University in 1820.

Despite Williams proof that the certain stimuli may cause the air
passages of the lungs to spasm, some physicians continued to
argue this in no way proved this had anything to do with asthma.
Other physicians, however, believed this proved nervous asthma
caused spasms of the air passages.  The above picture shows
how far science expounded upon the experiments of Williams
in the years between the publication of his work in 1840 and
the publication of Dr. Henry Hyde Salter's 1860 book,
Asthma: It's Pathology and Treatment." The caption under
the picture read: "Diagram showing the four ways in which the bronchial tubes may be narrowed.
1. Bronchial catarrh. 2. Recent bronchitis. 3. Old bronchitis 4. Asthma.  (6, page 39)

His father was Rev. David Williams, who came from an eminent family of many teachers and scholars. Along with being a Reverend, his father was also a successful tutor, having "prepared several gentle men for the university, who have since attained distinction as scholars." He educated his son at home until he was accepted at Edinburgh University in 1820, where he began his pursuit to become a physician. (1, page 1, 6, 9)

Williams credited his father with exposing him to subjects he wouldn't have been exposed to had he attended the public schools, subjects which would help him in his later endeavors, such as "Geography, History, Biography, Natural History, and above all, Natural Science." (1, pages 2-3)

Williams would have learned about Franz Reisseissen, who discovered in 1808 that muscular fibers wrap around the air passages of the lungs.  He would have learned about Rene Laennec, who believed Reisseissen's evidence was proof enough of both the spasmotic and nervous theories of asthma.

J.B. Berkart, in his 1878 book "On Asthma: It's Pathology and Treatment," said: (2, page 17)

Laennec assumed that they, being muscles, were endowed with contractility, and therefore liable to spasm. Such a spasm, he thought, might probably have been the cause of that fatal dyspnoea; but whether this supposition were correct or not, the case itself seemed to indicate the existence of a nervous asthma. Yet, notwithstanding the negative results of physical diagnosis and post mortem examination, he had doubts on the subject. Hesitatingly he admitted spasmodic asthma, with this limitation, however, that it generally consisted of nervous and organic affections combined.(2 page 17-18)

He would have been well aware of the evidence in support of the nervous theory of asthma, that asthma is a neurosis of the respiratory organs, that came from the papers of Francis Ramadge in 1835, the essays of Joseph Bergson and Amedee Lefevre in in 1836, and the verification of this evidence by the experiments of Moritz Romberg in 1841.   (4, page 506)

Williams must have been aware of these studies, and believed this evidence was too overwhelming not to support the nervous theory of asthma.

Yet other physicians did not believe this was enough evidence to support any theory, especially Dr. William Budd, who performed experiments in 1840 that he believed disproved the spasmotic theory AND the nervous theory of asthma.

Yet our doctor Williams would have something to say about Dr. Budd's experiments.  Dr. Williams would prove them wrong, and he did it that same year: in 1840.

Dr. Berkart explained:

As the bronchial contractility was denied as often as asserted, Dr. C. J. B. Williams again took the question in order to settle the matter in dispute. He, indeed, succeeded in showing, by experiments conducted with all necessary precautions, that mechanical, as well as chemical and electrical stimuli do produce contraction of the air-tubes. Thus the theory of a bronchial spasm obtained the support of experimental physiology. And even those who until then wavered in their opinions as to the possibility of such a spasm saw now no reason for doubting, but readily accepted that doctrine.  (2, page 26)

Still, while Reisseissen discovered that muscular fibers wrap around the air passages, and while Williams proved that they may spasm under certain circumstances, this did not prove that they spasmed during an asthma attack. (3, pages 193-194)

Berkart said:

Yet one link was wanted to complete the chain of evidence in favour of a bronchial spasm. As yet nothing was known of the innervation of the bronchi. Irritation of the vagus had produced no effect upon their calibres, and Dr. Williams was therefore led to conclude that "the muscular fibres seem not to be excitable through the nerves of the lungs."(2, page 26)

This evidence would also come in 1840 by the experiments of Dr. Francois Achille Longet.  

Williams was among the physicians of his era to support that idea that the definition of asthma was too vague, including too many ailments that cause symptoms similar to asthma yet have nothing to do with the lungs.  He therefore wanted to simplify the definition. 

Berkart said:

Dr. Williams himself, assuming a plus and minus state of contractility, described two forms of asthma—the one spasmodic, the other paralytic. The former was supposed to be represented by the isolated attacks of dyspnoea which generally accompany emphysema; the latter by those which appear in connection with chronic pituitous catarrh. (2, page 26)

Wolff Freudenthal, in his 1917 article in A Weekly Review of Medicine titled "Bronchial Asthma, said:

In 1841, Doctor (J. B.) Williams, in Tweedie’s Dissertations of Diseases of the Organs of Respiration, describes two forms of asthma—a spasmodic and an atonic or paralytic form. He found “that defect of these properties (excessive contractibility of the bronchial tubes) would disorder the process of breathing, and is led to believe that there may perhaps be a nervous asthmaor dyspnea “from weakness or paralysis of the circular fibres, or of the. nerves which regulate their contractions.” (5, page 2)

Williams was correct that asthma needed to be redefined, yet his most impressive contribution to the history of asthma was his experiment proving that the muscular fibers that wrap around the lungs may contract when irritated by certain stimuli.

Surely his experiment didn't prove the spasmotic thoery of asthma, yet it made this theory look highly probable.  His experiment met with little opposition for the next 14 years (Wintrich, 1854), and would be noted by nearly every physician writing on the subject of asthma for the rest of the century.   

References:

1. Williams, Charles J. B., "Memoirs of Life and Work," 1884, London, Smith, Elder, & Co. 
2. Berkart, J.B., "On Asthma: It's Pathology and Treatment," 1878, London, J. & A. Churchill
3. 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.
4. Whitaker, James Thomas, "The theory and practice of medicine," 1893, New York, William Wood and Company
5. Freudenthal, Wolff, "Bronchial Asthma," New York Medical Journal: A Weekly Review of Medicine, edited by Edward Swift Dunster, James Bradbridge Hunter, Frank Pierce Foster, Charles Euchariste de Medicis Sajous, Gregory Stragnell, Henry J. Klaunberg, Félix Martí-Ibáñez, volume CV, January-June, 1917 (Saturday, January 6, 1917), New York, A.R. Elliot Publishing, Co., pages 1-5
6. Salter, Henry Hyde, "Asthma: It's Pathology and Treatment," 1864, Philadelphia, Blanchard and Lea

Further reading:

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. Biermer, Anton., "On Bronchial Asthma," in the book, " Clinical Lectures on Subjects Connected with Medicine Connected with Medicine, Surgery, and Obstetrics," by various German authors, 1866, London, New Sydenham Society,  pages 171-194
3. Williams, Charles James Blasius, Alexander Tweedie, William Wood Gerhard, "Tweedies dissertations of diseases of the organs of respiration," 1841, London, Lea and Blanchard

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1819: Laennec says consumption can be cured

Dr. Rene Laennec might have become interested in diseases of the lungs because his own mother died of tuberculosis when he was only five-years-old.  Of course it may simply have been his desire to help people who lived under the gloomy cloud created by the grim diagnosis of the disease.

While he specialized in diseases of the chest, he would end up spending more time studying consumption than any other disease, perhaps becoming the first to describe the disease as curable. (1, page 6)

He referred to it as pthhisis pulmonalis in his 1919 book "Mediate Auscultation," dedicating three full chapters to the disease.  He said it results in the development of "species of accidental production" called the tubercle in the lungs. (2, page 283)

He said the ancients described an "accidental production" as any abnormality, and used the term "tubercle" to describe an accidental production in the lungs, such as a cyst or cancerous growth, that resulted in phthisis or wasting away.  (2, page 283, 310)

Laennec, however, recommended tubercle only be used to describe tubercles of consumptive patients. (2, page 283)

He described the tubercle:

Whatever be the form under which the tuberculous matter is developed, it presents at first the appearance of a grey semi-transparent substance, which gradually becomes yellow, opaque, and very dense. Afterwards it softens, and gradually acquires a fluidity nearly equal to that of pus; it being then expelled through the bronchi, cavities are left, vulgarly known by the name of ulcers of the lungs, but which I shall designate tuberculous excavations. (2, page 285)

He said in most cases the disease results in extreme emaciation, which is why the ancient Greeks referred to it as phthisis, wasting away.  (2, page 304)

He said the internal organs other than the lungs are usually of normal length, but of lessor diameter.  The chest is "usually narrow and sometimes evidently contracted." The skin is usually very pallid and pale.  (2, page 306)

He said:

"The emaciation then makes rapid progress toward complete marasmus (severe malnutrition).... The nose becomes sharp and drawn; the cheeks are prominent and red, -- and appear redder by contrast with the surrounding paleness; the conjunctiva of the eyes is of a shining white or with a shade of pearl blue; the cheeks are hollow; the lips are retracted, and seem moulded into a bitter smile; the neck is oblique and impeded in its movements; the shoulder blades are projecting and winged; the ribs become prominent, and the intercostal spaces sink in, particularly on the upper and fore parts of the chest. Sometimes even the whole chest seems contracted...; and this may actually be the case, particularly when the disease is very chronic, owing to the contraction and tendency to cicatrization of large tuberculous excavations. The belly is flat and retracted; the larger joints and those of the fingers, appear enlarged from the falling away of the neighboring soft parts; and even the nails become incurvated, in consequence of the absorption of the pulpy extremities of the fingers. No other disease gives rise to so complete emaciation as phthisis,—except cancer and continued fever of long duration. (2 page 372)

The patient sometimes complains of a "guggling sound," which Laennec attributes to the softening the the tubercles.  This is often expectorated, resulting in sputum similar to that produced during a fit of common catarrh. (2, pages 375-377)

The disease generally presented with obvious signs and symptoms.  The earliest symptom was a dry cough, which may be confused with dry catarrh. Haemoptysis, fever, chills and night sweats are other prominent symptoms. Some patients are known to require a change of sheets several times in a night. (2, pages 369-272)

Most people, including most physicians, during the early 19th century had a very gloomy view of this disease, as most who were diagnosed with it perished as a result of it.  The medical prognosis, therefore, was not very good.  (2, pages 319-320)

However, Laennec explained that the ancients believed "phthisis" started as a result of chronic inflammation, and they probably came to this conclusion because an early symptom of the disease is a slight dry cough that could easily be contributed to a dry catarrh (common cold). (2, page 319, 320, 369)

This chronic inflammation resulted in the gradual formation of pus in pulmonary tissue.  They believed this was curable, especially in the early stages. (2, pages 319-320)

This was pretty much the common perception of phthisis all the way up to the late 19th century when pathological anatomists discovered tubercles in the lungs of patients with phthisis.  (2, page 369)

Yet once physicians started studying pathological anatomy, they learned that this was not true, that once one developed tubercles (like cancer) the prognosis was poor, with death almost certainly imminent. (2, pages 319-320)

Laennec seemed to disagree with this notion, believing instead that, while the disease was not curable during the early stages of the disease, it was curable in the latter stages, that is, he said, "after the softening of the tubercles and the formation of an ulcerous excavation."  (2, page 321)

He said:

The formation of the semi-cartilaginous membrane on the surface of tuberculous excavations, must be considered, in my opinion, as a curative effort of nature. When completely formed, it constitutes a sort of internal cicatrix (a scar of a healed wound) analogous to a fistula, and is, in many cases, not more injurious to health than this species of morbid affection. All the persons whose cases I noticed above, died of diseases not referable to the pulmonary organs. They had all lived a greater or less number of years in a very supportable state of health, being merely subject to chronic catarrh. Some indeed had more or less of dyspnoea, but without any fever or emaciation. (2, pages 321-322)

Essentially, he believed that early on in the disease the tubercles were soft, and these were not curable. However, later in the disease scar tissue formed, either by fistula or cicatrix.  This hardened tissue acts as a natural barrier against the disease. (2, page 336)

While essentially cured, the patient may still present with symptoms. Generally, he believed those cured by fistula developed a chronic catarrh occasioned with sputum production that was sometimes copious; and those cured by cicatrix developed a dry cough that was not frequent, not severe, and not much of an inconvenience to the patient. (3, page 337)

He even gave examples of patients cured of consumption.

In a lady, formerly a patient of M. Bayle, fourteen years since, and whose case was decidedly consumption, (as appears from M. Bayle's notes in her possession,) the sign of pectoriloquy (particular lung sound made by a tubercle) is most distinct. This lady recovered beyond all expectation; she is now stout, and the only symptom she has at all referable to the lungs, is a slight cough. I have no doubt that the cartilaginous excavations above described exist in this person's lungs.

In July of 1817 he attended to a lady of 48 who had been in good health until the age of 30 when she became subject to severe attacks of catarrh and became quite emaciated.  Upon assessment he observed her breathing was diminished over the upper right chest.  By this, and by the appearance of her sputum, he diagnosed her with tubercles in the early stages.  As the treatment he applied leeches and more.  (2, pages 325-326)

Her symptoms were unchanged until February of 1818 when her cough increasingly distressing with thick yellow sputum.  He said:

I did not see the patient during this attack, which she looked upon as a cold; but I visited her in the beginning of April, and upon examining her chest I found most distinct pectoriloquy at the anterior and upper part of the right side. I was convinced by this that the supposed catarrh (the cold) had been the discharge of the softened tuberculous matter. The sound of respiration was good over the whole chest; and even in the vicinity of the pectoriloquous spot; the pulse was not frequent and the heat moderate. On this account I entertained hopes of her recovery, and prescribed ass's milk. The cough and expectoration progressively lessened, the flesh and strength returned; and, in the beginning of July, my patient had regained every appearance of the most perfect health. (2, page 326)

The pectoriloquy continued, although he suspected that it would, offering proof that she had suffered and survived a bout of consumption.  (2, page 322)

Laennec listed hundreds of various remedies used by the ancients and moderns, and he said any of these are worthy of trying, so long as the patient tolerates them, and this included bleeding with leeches and cautery by the application of caustic potass on several locations of the body.

The medicinal list also included a long list of expectorants, purgatives, etc.  It also included the inhalation of fumes, air of cow houses, oxygen, hydrogen, etc. (for a longer list of Laennec's remedies check out my post 1819: Laennec remedies for consumption.

The remedy he was most fond of, however, was change of situation.  (2, page 392)

Laennec said that the ancients observed that consumption was sometimes cured by the seaside, and that they often recommended sailing to their phthisical patients. He said Areteaus recommended sailing and the air of the seashore, Celsus recommended a voyage to Egypt.  (2, pages 243-394)

This was an idea recently picked up by English physicians, who often sent their phthisis patients to Maderia.   (2, page 343)

There was one case early on in his career, long before he had invented the stethoscope, whereby a patient of his was diagnosed by both himself and Dr. Bayle as having chronic catarrh.  However, upon a change of air, or a move to the seaside, he was cured.

Several years later, and after he had use of the stethoscope, he had another opportunity to assess this patient.  He said:

Since then I have had an opportunity of satisfying myself, by means of the stethoscope, that our patient had had more than a mere catarrh. His respiration is quite perfect throughout the whole chest, except at the top of the right lung, in which point it is totally wanting. On this account, I am certain that this portion of lung had been the seat of an ulcerous excavation, and that this had been replaced by a complete and solid cicatrice. The health of this gentleman continues good, although he has often occasion to speak in public. He has sometimes a little dry cough, on the change of weather, but takes cold very seldom. (2, page 340)

Yet while medicine may offer benefits to the consumptive, it does not offer a cure. The only means to a cure, he said, was nature.  (2, page 396)

So while he began his career under the belief there was no cure for consumption, his own experience and assessment skills proved that this was not always the case. He learned that there was a cure for consumption...

...or at least, for such a suspension of their symptoms as may be deemed almost equal to a cure, as the individuals may enjoy such a state of health as may enable them to fulfill all the duties of civil life, for several years, or until a fresh development of tubercles produces a fresh and final seizure. (2, page 337-338)

Patients who were thus "cured" might still have some symptoms, such as episodes of catarrh or a cough, but may otherwise "live in a supportable state of health." Others may have dyspnea, but without the fever and emaciation. (2, page 322)

As one final note to this discussion, Laennec said:

My experience leads me to deem such cases to be extremely common: those related above occurred to me in the course of some months: and I have since met with many others. (2, page 340)

Laennec was, therefore, among the first physicians of his era to speculate that consumption was a curable disease.  This subject would be further investigated by his pupil, Francis Ramadge.

It was perhaps due to his passion to learn about this disease that cost him his own life.  He would end up one of the many victims of consumption at the young age of 45.

References:

1. 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
2. Laennec, Rene, "Mediate Auscultation," translated by John Forbes, Notes by professor Andral, 4th edition, 1838, New York, Samuel S. and William Wood

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1819: Laennec defines pneumonia

By the year 1819, when Rene Laennec invented the stethoscope, little had changed regarding pneumonia since it was described by Hippocrates.  Treatment was also unchanged, as many physicians still recommended bleeding as a general treatment.

In his 1819 book, Mediate Auscultation, Laennec used his stethoscope to distinguish pneumonia from other pulmonary diseases.  He said that first it had to be separated from pleurisy, as calling it peripneumony as added to "confounded" descriptions of it. (1, page 512)

However Laennec continues to use the terom peripnumony.  He described three types of peripneumony. (1, pages 512-516)

1. Pneumonia complicated with slight pleurisy: It can be accurately diagnosed by crepitous rhonchus (fine inspiratory crackles) being heard over the part of the lung affected, which is usually the "roots of the lungs"
2. Pleurisy complicated with slight pneumonia: Crepitous rhonchus only at the roots of the lungs and the large bronchi
3. Pleuro-pneumonia: Pleurisy with severe pneumonia (1, pages 512-516)

The following are the recommended options: (1, pages 504-508)

1. Venesection, either general or local (to reduce congestion)
2. Cupping
3. No food for a few days
4. Getting out of bed several hours a day
5. Tartar emetic in large doses
6. Antimonials as an emetic
7. Kermes as an emetic
8. Mercury to treat inflammation 
9. Hot wine, brandy, and aromatics to treat fever
10. Blisters to the affected side to treat chronic pleuropneumony
11. Purgatives and diuretics, particularly when dropsy or hydrothorax occurs
12. Acetate of potass
13. Extract of squills
14. Watery infusion of digitalis
15. Nitre as a diuretic (1, pages 504-508)

Which of the above remedies is used, and the dosage, depends on the stage of the disease, and what comorbidities exist with it: does it present with a fever? Is it aucte or chornic? 

Pleurisy and pneumonia were pretty much treated the same, basically because they both present with inflammation.

References:

1. Laennec, Rene, "Mediate Auscultation," translated by John Forbes, Notes by professor Andral, 4th edition, 1838, New York, Samuel S. and William Wood, pages 84-87 for bronchitis treatment, and 175-177 for emphysema treatment
2. Andras, author of the notes in the book, "Mediate Auscultation, by Rene Laennec," ibid

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1819: Laennec describes causes of consumption

In 1819, when he wrote his book, "Mediate Auscultation," Dr. Rene Laennec, of France, had no idea that consumption, or what he referred to as phthisis pulmonalis and what we refer to as tuberculosis, was caused by a bacteria.  So, as with other physicians of his era, he was force to speculate based on his studies and own observations.

Some things he suspected as causing tuberculosis were:

1.  Cold:  It was more common in northern Europe and America where the temperature has a tendency to become cold.  It is less common in southern Europe and between the tropics.  In places where it is cold year long, such as high up in the Alps, people tend to prepare for cold weather better with warm clothing and houses. (1, page 341)

2.  Too light clothing:  This may give the impression of cold, particularly in young women whose disease typically begins with pulmonary catarrh, pneumony, or pleurisy.  (1, page 342-343)

3.  Locality: It is more common in large cities than in small ones, and more frequent in small cities than in the country. It was less common on the seashore than inland.  Sailing, or a long voyage at sea, tends to offer as a cure.  (1, page 343-344)

4.  Haemoptysis:  Many physicians suspected this cause inflammation that resulted in congestion of the vessels, leading to blood in the lungs.  However, Laennec wasn't convinced, suspecting the blood was a result of the tubercles in the lungs.  (1, pages 345-347)

5.  Depressing passions: Strong and long lasting passions, such as grief, tend to not only cause consumption, but cancers and other accidental productions as well.  He said people in the city are likely to come into contact with more people, "and is in itself a cause of more frequent and deeper vexation." Plus, in the city, people are more prone to be witness "the greater prevalence of immortality... a constant source of disappointment and misery." (1, page 347)

6.  Fevers:  Severe continue or intermittent fevers are a common cause of phthisis.

7.  Infected people:  A question Laennec postulated was: is consumption contagious?  He said it had long been suspected to be contagious, although he had seen many cases of people living together with a consumptive who did not themselves succumb to the disease.  Still, he said, the common people still suspect it is a contagious disease

While the exact cause may have eluded him, he was aware that, while Hippocrates suspected phthisis attacked people between the ages of 18-35, and Bayle suspected it attacked people between the ages of 40-40, Laennec believed that "no age was exempt from it." (1, page 352)

He did, however, believe women were more subject to it than men.  (1, page 353)

References

1. Laennec, Rene Theophile Hyacinthe, "A treaties on the diseases of the chest, and on mediate auscultation," tranlated by John Forbes, 1838, New York, Philadelphia, Samuel S. and William Wood, Thomas Cowperthwaite and Company

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1819: Laennec's treatment for emphysema and bronchitis

Laennec admitted himself to have been the first to accurately describe emphysema and bronchitis, and to note that they generally occur together.  While he offered no new remedies, he does offer an idea of how you would have been treated if you had COPD in the 1820s.

He referred to chronic bronchitis as chronic mucous catarrh.  If you were diagnosed with this, these would be your possible remedies.

In old persons:

• Permanent drain in the arm or thigh
• Use of aromatic bitters, such as hyssop, horehound, ground ivy, sage, veronica, &c.

If the expectoration suspended:

• Oxymel of squills, or kermes mineral, in small doses

If cough becomes hard and returns by fits:

• Peregorics are ordered

For long continuance of the disease: 

• Emetics, repeated according to the patient's strength and his power in supporting their action
• Tonics given in small doses after the emetic, such as barks and other bitters
• Preparations of iron take away the complaint or greatly moderate it
• Spirituous preparations particularly punch
• Balsam of tulu and capaiba
• Turpentine in 18-30 drops daily
• Internal use of tar water 
• Inhalation of fumes of tar water defused in the patient's chamber

When acute catarrh supervenes the chronic: 

• Blisters
• Cupping

When dyspnea becomes extreme: 

• Narcotics, particularly the powder of belladonna or strammonium in doses of half a grain to a grain
• Emetic of Squill, epecacuan, and kermes in small doses

He referred to emphysema as vesicular emphysema.  If you were diagnosed with this, these would be your possible remedies.

When caused by dry catarrh:

• Friction with oil lessons catarrh

In cachectic subjects:

• Subcarbonate of iron lessons catarrh, diminishes congestion of mucous membrane and diminishes spasmotic stricture of the bronchi

In severe asthmatic paroxysm:

• Venesection to relieve congestion of blood in the lungs
• Narcotics to diminish the necessary of respiration

If you became short of breath with either of these conditions, you would still be referred to as having a fit of asthma.  However, the cause, if your physician was observant enough, would be different.  Even the treatment might be different, at least to a slight degree

References:

1. Laennec, Rene, "Mediate Auscultation," translated by John Forbes, Notes by professor Andral, 4th edition, 1838, New York, Samuel S. and William Wood, pages 84-87 for bronchitis treatment, and 175-177 for emphysema treatment
2. Andras, author of the notes in the book, "Mediate Auscultation, by Rene Laennec," ibid

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1819: Laennec accurately groups emphysema and bronchitis

Laennec accurately described emphysema (13)

Dr. Rene Laennec was known as the father of chest medicine, and this is mainly due to the fact he was the first to have the tools necessary to compare what he learned upon assessment of the chest during life, with what he saw when inspecting the lungs during autopsy after life.

The tools he had access to were chest percussion and the monaural stethoscope he invented. He used these to perform complete assessments of the chest on any of his patients who complained of asthma or asthma-like symptoms, such as dyspnea, chest tightness, chest pain, increased phlegm, and coughing. By doing this he became the first physician to accurately distinguish asthma from chronic bronchitis and emphysema.

That said, here is how he described bronchitis and emphysema.

Bronchitis:  He defined it as "Chronic Mucous Catarrh."

He said bronchitic airways are sometimes present with a "general or partial dilation of the bronchi.  Pulmonary vessels are often congested, and this can often be diagnosed by sputum that is tinged with blood. In fact, while the amount expectorated varies from day to day, colorful sputum is almost always produced. However, when the person becomes weak, expectoration may become difficult. (2, page 81)

He said bronchitis usually occurs in the aging, and usually after a severe acute attack, and as it worsens often produces dyspnea.  (2, page 83)

He said if it does occur in the young, however, it usually disappears in a year or two.  However, the only time it disappears in the aging is during the summer months, only to return during the winter months. In such cases it usually returns with a fever and copious expectoration.  After a few times of this happening... (2, page 83)

...it terminates in a continual mucous catarrh... the great expectoration of which weakens and emaciates the patient." (2, page 83)

Since he had access to his stethoscope, he would use it to help him diagnose chronic mucous catarrh.  He would generally hear "mucous rhonchus, sometimes indeed pretty loud and abundant, but very rarely continuous, and still rarely general over the chest." (2, page 83-84)

Laennec said emphysema has been described by some previous authors -- Bonetus, Morgagni, and Floyer,  who observed emphysema in a "broken winded mare" --although "none of these various authors appear to have been acquainted with the real character of the affection, viz -- dilation of the bronchial cells." (2, pages 161,165)

So he said it had never been accurately described. There were two exceptions to this, and these include Ruysh and Valsalva. (2, page 165)

Some might say that Dr. Ballie accurately described emphysema, but Laennec disagrees.  He said:

Dr. Baillie, author of the Morbid Anatomy, has correctly observed the three principal circumstances which constitute emphysema of the lungs, namely—the great size of these organs,—the dilatation of the cells,—and the vesicles formed by the extravasation of air under the pleura; but he does not appear to have been acquainted with the mutual dependence of these three states, and describes them as three different affections. (2, page 166)

In fact, he said that even he thought it was a rare disease until he started making use of the stethoscope.  Since then he said he has verified it in the living as well as the dead.  In fact, he became so adept at diagnosing it that he figured that many cases previously defined as asthma were actually emphysema.  (2, page 161, 163, 165)

He defined it simply as...

...dilation of the air cells... the cavity of these dilated cells descends some little way into the substance of the viscus, and there its walls do not collapse... the bronchial tubes, especially those of the small calibre, are sometimes very evidently dilated in those portions of the lung where the emphysema exists. (2, page 161-163)

He observed that while many of the cells were dilated, some were ruptured. Interestingly, Laennec said:

When we blow into an emphysematous lung, the dilated and projecting cells seem to become flatter the more they are distended, and fall down to the general level of the surface. This is owing to the greater relative extensibility and elasticity of the healthy cells, which in the first instance rise to the level of the dilated cells, and then fall below them, to their natural level. The continued projection of the dilated cells may be partly owing, also, to the difficulty with which the air escapes from them, more especially when the exciting cause of the emphysema is the dry catarrh. (2, page 163)

He also said:

On placing an emphysematous lung in a vessel of water, it sinks much less than a healthy lung; sometimes it floats on the surface with scarcely any obvious immersion."  (2, page 164) 

Laennec became the first to describe emphysema due to aging, and he was the first to define emphysema as tissue damage in the peripheral air passages. He further defined emphysema as a breakdown of tissue in the parynchema of the lungs as opposed to air trapped in the alveoli due to an obstruction such as occurs in asthma and bronchitis.

He said the disease could be diagnosed upon autopsy, although he further stated it could be diagnosed in life by using the stethoscope. He said:

The respiratory sound is inaudible over the greater parts of the chest, and is very feeble in the points where it is audible... from time to time, while exploring the respiration or cough, a slight sibilous rhonchus... by the displacement of the pearly sputa. (2, page 172)

He also noted other signs that emphysema should be diagnosed over asthma: (2, page 172)

• Diminished lung sounds
• The long continuance of the disorder (chronic)
• The severity of the habitual (chronic) dyspnea
• The asthmatic paroxysm occasionally occurring
• The cylindrical form of the chest (barrel chest)
• The slight lividity of the skin
• Occasional dry crepitous rhonchus on inspiration or with cough (inspiratory crackles due to secretions)
• Occasional crackle where the rhonchus is heard
• When the complaint is of long standing and the patient far advanced in life, the paroxysms become more frequent and severe

M. Andral suggests that the dry crepitous rhonchus described by Laennec was the first description of crackles "at the moment of rupture of the air cells."  In modern medical language, this would be crackles on inspiration due to the alveolar cells popping open.  This may have been the first description of this commonly heard lungsound. (3, page 173)

Interestingly, Laennec offers the following about the prognosis of this disease.

Pulmonary emphysema.  is not a disease of great severity.  Of all the varieties of asthma it is unquestionably that which affords to the patient the best prospect of long life. The long continuance and slow progress of the disease and the nature of its causes, render it possible to struggle against the organic lesion, and permit the functional disorders resulting from it to be kept within tolerable bounds (3, page 174)

In this way, it was Laennec who became the first to distinguish chronic bronchitis and emphysema as separate entities from asthma.  He was the first to speculate that they ought to be extricated from the umbrella term asthma, to become disease entities of their own with their own treatments.

References:

1. Petty, Thomas L, "The History of COPD,"Int. J. Chron. Obstruct. Pulmon. Dis., 2006, March; 1(1): 3-14
2. Laennec, Rene, "Mediate Auscultation," translated by John Forbes, Notes by professor Andral, 4th edition, 1838, New York, Samuel S. and William Wood
3. Andras, author of the notes in the book, "Mediate Auscultation, by Rene Laennec," ibid
4. Laennec, Rene, "A Treaties on the Diseases of the Chest and on Mediate Auscultation, " 1834, London (copius notes by John Forbes)

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1819: Laennec is first to describe lung sounds

After he invented the stethoscope in 1819, it was then next task of him to perform experiments with it.  As he was the first to auscultate with this device, he would also be the first to describe lung sounds.

He noted first normal lung sounds, although he did not refer to them as clear as we do today.  He also noted an array of adventitious noises in the lungs among those who were not healthy, and for this he needed a name.  He said:

For want of a better or more generic term I use the word rhonchus* to express all the sounds, besides those of health, which the act of respiration gives rise to, from the passage of the air through fluids in the bronchi or lungs, or by its transmission through any of the air passages partially contracted. (1, page 55)

M. Andrus said Laennec chose the term rhonchus because...

...It was desirable that some name might be found for this phenomenon which would prove generally acceptable to British physicians.  In the former edition of this translation, the nearest English synonym, rattle, was used, but this word has been adapted by few.  The original French term rale appears to be most generally employed in this country, but there are several objections to its use. (1, page 55)

Today, the term rhonchi is used to describe the sound of air moving through secretions, and the term wheeze is used to describe the sound of air moving through air passages partially contracted.  Rhonchi is generally heard as a coarse sound, is continuous, and is often times confused as a wheeze.

Laennec avoided this confusion simply by calling all continuous sounds rhonchi. Today, many medical caregivers avoid the confusion by calling all continuous lung sounds a wheeze.  So there really is not much difference here other than the term used.

While we generally describe the various lung sounds as clear, diminished, rhonchi, wheeze and crackles, Laennec basically described five types of rhonchi, as follows (modern term I think he is referring to is in parenthesis): (1, pages 55-62)

1. Moist crepitous rhonchus, or crepitation:, similar to the sound of blowing into a dried bladder, or the sound made by rubbing between the finger and thumb a piece of hair, or the noise of boiling butter.  This is a sign of the early stage of peripneumony and edema of the lungs and pulmonary apoplexy (crackles)
2. Mucous rhonchus, or guggling: Formed by the passages of air through sputa in the bronchi, and sounds like bubbles, or blowing through a pipe into soapy waters. The sound of the bubbles can be described as middling, small, large, or very large, and is a sign of peripneumony or suffocative catarrh in old people near death (the death rattle) or those dying of phthisis, or hemoptysis, or phthisis, or diseases of the heart, or tuberculosis excavations, and may be regarded as an evil omen (tracheal Rhonchi, large airways, or upper airway rhonchi, and may be audible, as in a death rattle)
3. Dry sonorous rhonchus, or snoring: Crackling rhonchus; Flat grave sound, sometimes extremely loud, sounding like a person snoring, and may be diagnostic of pulmonary fistula, or dilated bronchi, and may be caused by temporary inflammation or contraction of the bronchi (rhonchi or sonorous wheeze, )
4. Dry sibilous rhonchus, or whistling: Prolonged whistle flat or sharp, dull or loud, and may sound like the chirping of birds, and may be caused by thick secretions obstructing the airway or local contraction of the smaller bronchi (wheeze)
5. Dry crepitous rhonchus, with large bubles or crackling: The sound of air entering lungs that had been dried, or air cells or vesicles (alveoli) that had been unevenly dilated, may make noise similar to that produced when blowing into a dried bladder.  May be indicative of emphysema  (fine inspiratory crackles heard upon the opening of previously collapsed alveoli) (1, pages 55-62, 98)

Andral said he would differentiate the rhonchi based on whether the cause was in the air cells (alveoli), the air passages (bronchi) or some morbid excavations formed in the substance of the lungs (secretions). He would break the sounds down this way: (2, page 55)

• Vesicular Rhonchi: Originating from the vesicles or air cells (alveoli)
• Bronchial Rhonchi: Originating from the bronchial tubves
• Cavernous rhonchi: Originating from morbid excavations

He further noted that lung sounds are either humid or dry.  (2, page 55)

He would then break them down this way: (2, pages 55-56)

1. Humid vesicular rhonchus: Moist crepitous rhonchus, Rale crepitant of Laennec (coarse crackles or rhales)
2. Dry vesicular rhonchus: Dry crepitous rhonchus, rale crepitant  (fine inspiratory crackles)
3. Humid bronchial rhonchus: Mucous rhonchus (Rhonchi)
4. Dry bronchial rhonchus: Sibilous rhonchi, rale sibilant (wheeze)
5. Humid cavernous rhonchus: May be caused by abscess or gangrene of the lungs or the later stages of tubercle or phthisis, and may sound like mucous rhonchus or guggling, and is usually over a small spot (as in just over the area affected, and is usually heard with deep inspiration or while coughing)
6. Dry cavernous rhonchus: described because it is possible, not that it has ever been described by any author (2, page 55-56)

Andral said that little was added to the description of rhonchus between the time of the first edition of his book in 1819 and the 4th edition in 1838.  He noted that a flaw in Laennec's description of the various lung sounds was that he did not mention at what point during the respiratory phase the sounds were heard. (2, page 62)

Andral said this was an important thing left out, because some sounds are heard only on inspiration, or only on expiration, and sometimes both.  So he added the following:

• Crepitous rhonchi or vesicular rhonchi: heard only on inspiration because it is a noise produced by the air vesicles cracking open
• Humid Bronchial rhoncus: heard during inspiration and expiration, and mostly during expiration because it is the sound of air moving through secretions, and the secretions are there at all stages of respiration
• Sibilous and sonorous rhonchi, or dry bronchial rhonchus: Heard oftener during expiration more so than inspiration
• Mucous rhonchus: Heard during both inspiration or expiration

So you can see that little has changed regarding the description of lung sounds other than the terms used.  The terms often varied from one author to the next, and this is true even to this day.

References:

1. Laennec, Rene, "Mediate Auscultation," translated by John Forbes, Notes by professor Andral, 4th edition, 1838, New York, Samuel S. and William Wood
2. Andras, author of the notes in the book, "Mediate Auscultation, by Rene Laennec," ibid 

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