1769: John Millar writes about asthma

John Millar (1733-1805) was a Scottish Physicians.  He cared for patients of all ages, although he tended to favor caring for women and children. So when an epidemic of asthma ravaged through the border counties of England and Scotland after great quantity of rain fell in 1755, Dr. Millar was among the first physicians called. (1, pages 11-14)(4, page 96)

He arrived on a blustery day, and was called to the home of a Baker.  A short, stout man wearing a white apron that was covered with white powder met the doctor as his buggy was parked by the entry of the Bakery.  The doctor could smell the sweet aroma of bread, and his stomach grumbled.  He climbed down from the buggy, reached back in for his bag, and followed the baker into his shop, up a narrow and steep set of winding stairs, to a small, hot, room, where a girl was sitting on the edge of a bed, leaning with her face on the edge of a window that faced the street.  He could hear a loud wheeze each time she took in a breath.  He could see by the vigorous shaking of her body that she was working arduously to suck in every breath.

He did not request for the girl to move, and instead squeezed his way around the bed and sat next to her, setting his bag along side him on the back of the bed.  He put his arm around the girls shoulder and hugged her.  "I'm going to help you feel better," he whispered.

He felt her head, and observed it was hot and clammy.  He also observed that she had picked away all the paint on the ledge of the window.  He touched her stomach, and his hand rode in and out as it undulated with each breath.  He said, "Does your stomach hurt? Are you sore down here?"

The girl did not respond, except by her tears and distressing look on her reddish face.  Her mother, however did respond.  She said, "She complained of a sore stomach, and she felt nauseated and vomited.  And she has been very nervous the past few days, refusing to go to school and to do her chores." Her husband, the baker, put his arm around her shoulder and held her tight. "We were so mad at her.  Now we wish we hadn't been."

"You didn't know," the doctor said.  "I believe her stomach indigestion, the fact that he suffers from a nervous affection, perhaps as from a hysteric or hypochondirac disease, and I presume it is asthma."

The doctor reached into his bag and pulled out a bottle and a spoon. He opened it and gave it to the girl.  He would give it to many sick girls and boys that day.  The last stop was at the house of a lawyer, whose girl was in the early stages of the disease.  She seemed to get immediately better when given the remedy.

The lawyer's wife asked him if he wanted to stay in the guest room, and he admitted he was tired.  Before he slept, he opened his bag and pulled from it a journal.  He wrote about every patient, and what he gave.

The next morning he went from business to business, home to home, to see other children, and a few adults, who were afflicted with this asthma.  At night he found a place to sleep, usually by the mother of the last child he saw that day, although on the last night before he planned to return home he slept in the Mayor's guest house.

It had been two weeks since he began treating sick children, and he had traveled from town to town, and had been treated well everywhere he traveled. Many children were cured by his remedies, although, a few times, he held a child during the last moments of life.

After a large meal cooked by the mayor's wife, he returned to the guest house for the night and pulled his journal from his bag.  He sat at a desk and wrote as much as he could remember about the past two week's events.  He wrote:

"Peruvian bark given early, seldom failed to perform a cure... the asthma was more or less frequent according to the state of the weather, that it prevailed most in spring and autumn, and especially in moist seasons. (1, pages 9-11)

He wrote that pure (spasmodic) asthma is most prevalent are places that have increased moisture, and have a tendency to be cold and damp, with the asthma presenting mostly in the spring and autumn. The remedy for this type of asthma is Peruvian bark. Without treatment death may ensue, or "remissions become less and less distinct." (1, pages 11-14)

While Millar described this epidemic as asthma, it was actually croup or some other related disease.  About 50 years later, after he had invented the stethoscope for listening to lung sounds, French physician Rene Laennec determined that the same disease was actually suffocative catarrh.  (4, page 96)

In the meantime, after caring for hundreds of children with what he considered to be asthma, Dr. Millar took his notes and decided to write a book to educate other physicians about this disease.  In 1769 his book was published as "Observations on the asthma and on the hooping cough."

Because his asthma was different than that described by ancient physicians, and even by other physicians of his era, he believed the ancients must have been wrong in their definition of asthma.  He wrote:

THE accounts which have been given of the Asthma by medical writers, seem only applicable to very advanced stages of it, or to other disorders, accompanied with a symptomatical difficulty of breathing; but perhaps without some previous knowledge of the original disease in its simplest form, more complicated cases can neither be clearly explained nor properly treated. The Author of the following Observations, having often seen it in children, unattended with any other complaint, hath given a description of it, as it really appeared, though very different from that which is to be found in books. (1, page i, ii) 

He said Hippocrates was the...

...first who to posterity a genuine history of diseases, and a rational method of treating them, founded upon faithful and accurate observations; but the simple and natural mode of medicine was soon vitiated by the introduction of false and absurd systems of philosophy. While such absurd theories were taught in the schools of medicine, the practice deduced from them was no less ridiculous; and as one or other of these opinions prevailed, the attention of the physician was employed in searching after medicines possessed of occult powers..."

Dr. Millar believed that it wasn't until the writings of Dr. William Harvey in 1628, who demonstrated "the circulation of the blood," that a rational practice of physic (medicine) was re-established. He said it was only after Harvey's discovery that a true understanding of the human body and its diseases could be learned. (1, pages 1-3)

The "theory and practice of physic" was only then begun.  It was Harvey's observation that resulted in "a careful attention to the rise and progress of disease, and to the effects of the medicines applied to them, (and this) is the only proper way to complete their history, and to establish a certain method of cure."  (1, pages 1-3)

He said that...

...Physicians fully convinced of this, and that no single person is sufficient for so great an undertaking, have long since established societies for collecting and publishing medical observations, which have contributed greatly to the improvement of the art." (1, page 3)

This was similarly noted by historian Fielding Hudson Garrison, who explained that there was an explosion of medical knowledge during the course of the 18th century, particularly regarding human anatomy, internal diseases, clinical medicine, and internal medicine.  Various physicians studied the human body, learning about the various diseases and the remedies that treat them.  (2, page 300, 330) 

Thanks to the discovery by Harvey regarding circulation of the blood, medicine as we know it today was born.  It was this discovery, and the eventual acceptance of it, that inspired physicians to race to learn as much about the human body as possible, and the ailments that plague it, and the remedies that fix it.  The result of all this research, and the discoveries that followed, squashed many of the old theories that enveloped the medical profession.*

Asthma was among the diseases studied and expounded upon, with physicians slowly coming to the realization, as noted by both Millar and his contemporaries, that asthma was more than a general symptom. 

Millar said asthma was among the diseases that was slow to be accurately defined.  He wrote:

Sir John Floyer, who was himself afflicted with this disease, describes the chronic asthma, and gives a just detail of its symptoms: but as he was first seized with it when a child, he gives no account of its beginning, nor of the method of treating that early period of it, in which, perhaps, alone a perfect and complete cure is to be obtained? .

What he is trying to say here is that Floyer only recognized adult asthma as opposed to infant and childhood asthma.  Millar continued:

Most other authors who have wrote on this subject, treat, under that denomination, of the Peripneumony, peripheral vomica, Pulmonum, Flatus,. Hypochondriac and. Hysterick Diseases, and, indeed, of almost every other disorder, accompanied with difficult respiration, excepting the least complicated state of that which they undertake to describe.

Here he is trying to say that most authors described asthma as the symptoms of shortness of breath, which is probably secondary to some other malady, as opposed to asthma in its pure form.  He said:

This will not appear surprising when we consider that an asthma, or difficulty of- breathing, is a leading symptom, in all the diseases already mentioned, as well as in many others; and, as it is painful and alarming, the patient, tho' a symptom only, deems it a primary disease, wishes ardently to be freed from it, and represents it principally to the attention of the physician.

On the other hand, as the least complicated species of asthma generally attacks children, or very young subjects, it is frequently confounded with the epilepsy, worms, teething, and other disorders incident to the early period of life, in which the physician can avail himself but little of the information of his patient, and is often misled by that which he obtains from others. Hence the accounts of it which we meet with in medical books, tho they may correspond to certain stages of it, or to the appearances of other diseases, in which a difficulty of breathing is a leading symptom, yet they convey no explicit idea of the origin and progress of the asthma in its simple uncomplicated state. (1, pages 4-5)

Basically he's saying here that there's more to asthma than what has been written about it by previous writers.  Millar breaks asthma down into the following categories.

1. Acute:  "Terminates in a few days in death, a perfect recovery..." (1, page 92)
2. Chronic:  It's "often a consequence of (acute asthma), and frequently continues for many years, and often during life." (1, page 92)  

The subheadings that follow here are my own, although I think this would be how Millar defines asthma the disease, as opposed to asthma the symptom of some other disease: 

1. Pure Asthma: "difficulty of breathing alone, which proceeds from some defect in the bronchial vessels."  (1, page 92)
2. Secondary Asthma:  Asthma occasioned by " an inflammation, or any obstruction of the lung, a pleurisy, perepneumony, hydrops pectoris, ascites, or any other ailment whither it appears as a concomitant or consequence of these.  

Over a hundred years later, when writing a book on asthma, Dr. Francis Ramadge would use Dr. Millar as a perfect example of how much was written, or assumed, about asthma without doing much investigating into the matter.  

Ramadge quoted Dr. Millar as saying:

The only dissection I ever made in the disease was of a child... (3, page 97)

Perhaps Millar was noting awareness of his limitations when, in the introduction of his book, he acknowledged that what he observed, and later concluded, about asthma was merely the beginning; that there was much more work to be completed regarding the definition of our term asthma.  He said:

Conscious of the difficulty of such an attempt, he does not suppose that he hath completed the history of the disease, but hath endeavoured to collect such observations, as may facilitate the further investigation of it; to point out the particular signs that distinguish it from other disorders in which respiration is only accidentally affected; and he proposes a method of cure which hath often been successfully applied, (1, page ii)

And he was right.  A wise asthma doctor indeed was he, or so we suppose, for the era for which he lived.

*For a list of all the diseases learned about check out reference Fielding Hudson Garrison's book, page 300-302.  He also lists the authors of various "histories of medicine" that were written during the 18th century.  See reference #2 below, or click here. 

References:

1. Millar, John, "Observations on the asthma and on the hooping cough," 1769, London
2. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1913, 1st edition, Philadelphia and London, W.B. Saunders and Company
3. 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
4. Andral, M, notes, Renae Laennec, author, "A Treaties on the Diseases of the Chest and on Mediate Auscultation, Regius Professor of Medicine in the College of France, Clinical Professor to the Faculty of Medicine of Paris, &c, &c, &c., Translated from the Third French Edition with Copious Notes, a Sketch of the Author's Life, and an Extensive Bibliography, of the Different Diseases by John Forbes, Member of the Royal College of Physicians, Physician to the Chichester Infirmary, and Physician in Ordinary to his Royal Highness the Duke of Cambridge, to which are added the Notes of Professor Andral, Contained in the Fourth and Latest Edition, Translated and Accompanied with Observations on Cerebral Auscultation, by John D. Fisher, Fellow of the Massachusetts Medical Society," 1838, New York, Samuel S. and William Wood

RT Cave Facebook Page
RT Cave on Twitter

1830-1836: Kropp and Hirsch still think asthma is croup

We are now transported into the 1840s in our asthma history. Medicine has evolved so that physicians are now looking to improve knowledge of our disease. While many suspect it's a nervous and spasmotic disorder, others have their own theories.

In the year 1841 Dr. Charles J. B. Williams proves that bronchial muscles may spasm, and this is a revolutionary breakthrough for us.  While a few physicians continue to try to prove him wrong, most accept asthma is, after all, both nervous and spasmotic.

Ye there continues to be those who believe asthma is more than just a disorder of the lungs.  There continues to be physicians who believe any organic disease that causes dyspnea is indeed asthma, yet those physicians are becoming increasingly rare.

Dr. J. F. Kopp (Kropp) and Hirsch (Hirsh), both of Koeningsberg, Germany, are two such physicians who believe asthma is caused by swelling of the vocal cords and larynx. Perhaps because of their work, their fellow German physicains often referred to it as thymic asthma or Kopp's asthma.

According to an 1836 article in the London and Foreign Medical Review, Dr. Kopp read a paper at an anual meeting of scientific men in Koeningsberg that was republished in 1830. Dr. Hirsch then wrote a paper in 1835 basically confirming the findings of Dr. Kopp with some of his own cases studies. (7, page 237)

The disease, or symptoms as some referred to them, had various names, depending on who was describing them.  Some included: (1, page 207)(2, page 202)(3, page 2)(7, page 239)

• Thymic asthma, or asthma thymicus (thymicum)
• Kopp's asthma
• Kopp's asthma thymicum
• Millar's asthma
• Hypertrophy (enlargement) of the thymus
• Asthma infantum
• Spasm of the glottis
• Enlargement of the glottis
• Croup
• Crowing (crouplike inspiration of children)
• Laryngismus stridulus anglorum (Harsh laryngitis)(1, page 207)(2, page 202)(3, page 2)(7, page 239)

Regardless of the name, the disease often results in "episodes of suffocation, during which respiration appears suspended, and which return periodically, especially on awakening or attempting to swallow, or when the child utters cries," according to an 1836 edition of the Dublin Journal of Medical Science. (4, page 514)

Andras said the German physicains usually referred to their "thymic asthma" as affecting mostly children between the ages of three weeks and eighteen months.  He said "it may last long, gradually augment in intensity, and prove fatal." (8, page 439)

An 1836 edition of the British and Foreign Medical Review summarized Dr. Kopp's description of an asthma attack as follows:

It is characterised by attacks of spasm of the chest and severe fits of suffocation. The breathing suddenly stops, or rather there is an extremely slight, piping, imperfect inspiration, forced, as it were, through the contracted glottis. The respiratory sound has some resemblance to the crowing inspiration of hooping-cough, but is much smaller and more acute; it is still more like the choking attempts at inspiration made during the hysteric spasm. In some cases, but rarely, there may be five or six piping or whistling inspirations, and then a few deeper and stronger. alternating with expirations so slight as scarcely to be perceived. In extreme attacks, the respiration stops entirely; the small inspiratory pipe then takes place, either in the beginning of the paroxysm or in its termination, being quite suppressed during the strength of the attack; and this symptom is pathognomic of the affection. The other symptoms are necessary consequences of the suppressed respiration; the body is extended forcibly backwards or the limbs drawn close up together; the face, which is fixed and expressive of great distress, is either purple or quite pale; the nostrils are expanded, the eyes fixed, the hands cold, the thumbs contracted, with involuntary dejections, &c. After a period of half a minute or a minute, occasionally even two or three minutes, the paroxysm ceases; the infant then cries for a short time, and immediately becomes cheerful and easy. When the constitution is very feeble, however, or the attack has been very severe, the child remains some time languid, pale, and sleepy. In the intervals of the paroxysms the child is quite well, without the slightest affection of the respiration. (7, pages 238-239)

The same article notes that death does occur at times.  It said:

On examination, besides the general appearances always following death from suffocation,—such as blueness of the skin, congestions of blood in the lungs and brain, &c,—the thymus gland is always found considerably enlarged. The degree of enlargement varies extremely, as does the natural size of the gland. At times it is enlarged chiefly in length and breadth, more commonly, however in thickness: in the last case the lungs are frequently thrust back by it into the posterior part of the chest; on other occasions, the gland is found closely connected with, and even surrounding, the large arteries and venous trunks of the thorax or neck." (7, page 239)

So what predisposes a person to an attack of this kind of asthma? The Medical Reveiw said Kopp beleived that "All diseases of the respiratory organs predispose to it,—such an catarrh, bronchitis, croup, hooping-cough, measles. Teething also predisposes to it." (7, page 239)

And the nature of the disease is as follows, again according to the Medical Reveiw:

It is an affection peculiar to early infancy, and consists of a periodical tonic spasm of the lungs, larynx, and glottis, perhaps also of the heart, eventually extending to the whole nervous system, under the form of epileptic convulsions. In it the thymus gland is more or less enlarged, but otherwise not diseased, and presses on the heart, bronchi, and large vascular trunks, impeding their functions. When, on examination after death, such an enlargement and abnormal compression exist, one need not seek further for proofs of the nature of the disease. (7, page 239)

Then the treatment is listed as follows: (7, page 240)

1. In the attack nothing more can be done than to place the child in a proper position, to rub its spine, perhaps to dash cold water on it, &c.
2. After the attack, to give antispasmodics, preparatory to the employment of means directed to the chief pathological state.
3. To diminish and prevent the recurrence of all undue congestion and nervous excitement in the heart and lungs, by low diet, large and frequent local bleedings (every four or eight days,) blisters and issues on the chest, constant powerful purgatives, &c.
4. To lessen the size of the thymus by anti-scrofulous, resolving medicines,— such as mercury, iodine, &c. (7, page 24)

William Stokes, in his 1837 book, described the exciting causes of Kopp's asthma. He said:

In this affection it is held, that any sudden emotion, causing a quick or forced inspiration, may bring on an attack of dyspnoea and suffocation, and even in some cases convulsions, so that in this way sudden death may supervene in a child, to all appearance perfectly healthy.

The Dublin Journal of Medical Science said the cause is "too great a development of the thymus gland."  Regarding the etiology (cause) of Kopp's asthma, Stokes said:

As yet the etiology of this disease is by no means established. and further researches are necessary to show how the condition of the thymus produces so remarkable an effect;—does it take an active part in these attacks, or is its permanent enlargement a passive cause for the injury? No data exist to answer these questions; but, from the similarity of cases of the crowing disease with those in which an enlarged thymus has been found, it seems probable that a morbid state of the thymus takes occasionally some part in causing the symptoms of Miller's asthma infantum. (2, page 202)

Dr. G. Lingen, in an 1839 article, said there were other physicians who supported this theory of asthma, but there were also those who did not.  He said:

English practitioners, however, as also the Germans Caspari and Pagenstecker, supposing that the hypertrophic state of the thymus is likely to be the effect and not the cause of this disease, contented themselves with assigning merely a symptomatic name for it, viz: Laryngismus stridulus, crowing or crouplike inspiration of children. But since Kopp and those practitioners who assisted him with their observations,  have vindicated the name of Asthma thymicum at least for those cases, which fell under their observation, and since other practitioners, equally creditable, have met with a disease resembling the one described by Kopp, without having found any anomalies of the thymus what ever; it is evident, that Kopp's Thymic Asthma and the Laryngismus stridulus Anglorum are diseases, apparently similar in their symptoms, but different as to their exciting causes. We say apparently similar, for it remains questionable whether the symptomatology of either of these diseases is completely known, so that, through further observations, a diognosis may yet be pointed out. (1, page 207)(see 7, page 240 for varoius arguments against Kopp's Asthma)

These diseases would not be further explored and diagnosed until they were once and for all removed from the rubric term asthma.  This is what would happen within the next few years, if the task wasn't already accomplished by some physicains.

Wolff Freudenthal, in a 1917 article in the New York Medical Journal, said the writings of Kopp and Hirsh represented the last hurrah for croup while still under the umbrella term asthma.  It would soon thereafter, thanks to the invention of the stethoscope and the discovery by Williams, be extricated from the rubric term asthma to become a disease entities of their own.

Freidenthal said:

They (Kopp and Hirsch) describe the now well known form of hypertrophy of the thymus, and the symptoms are clearly those of pressure on the trachea. There was no sign of asthma in the cases reported, but only dyspnea and the characteristic breathing of partial occlusion of the trachea. (3, pages 2-3)

A great many other varieties of dyspnea arising from various organic diseases had been previously described, and this so called thymic asthma of Kopp and Hirsch is the last one of its kind. At that time the difference between dyspnea and asthma was gradually being cleared up, and this was mostly due to the introduction of auscultation and percussion. (3, page 3)

So thanks to the discoveries of men like Williams, coupled with better methods of diagnosis, the nervous and spasmotic theories of asthma moved into the foreground, and croup was extricated from the rubric term asthma.

Note:  Despite an extensive search, I could find no further information regarding Kropp and Hirsch. 

Further reading: 

• 1733-1805:  John Millar writes about asthma (4/23/15)

References:

1. Lingen, G., "A Case of Asthma Thymicum Koppi, or Laryngismus Stridulus Anglorum, Crowing or Croup Like Inspiration," in the book "Miscallanies of Homeopathy," edited by an association of homeopathic physicians, 1839, Philadelphia, L. J. Kinderlen, pages 207-210
2. Stokes, William, "A Treaties on the Diagnosis and Treatment of the Chest," 1837, Philadelphia, A. Waldie
3. 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
4. "Scientific Intelligence: Memoir on Thymic Asthma," , Dublin journal of medical science, volume IX, 1836, Dublin, published by Hodges and Smith, pages 514-522
5. Montgomery, W.F., "Dr. Montgomery on the sudden death of children," London Medical Gazette, volume XVIII, Volume II for the sessions 1835-1836, 1836, London, printed for Longman, Rees, Brown, Green, and Longman, Paternoster Row, pages 828-833, reference to Kopp and Hirsch on page 833
6. "Memoir of Thymic Asthma, compliled chiefly from the papers of Dr. Kopp and Hirsch of Koeningsberg," volume XVIII, Volume II for the sessions 1835-1836, 1836, London, printed for Longman, Rees, Brown, Green, and Longman, Paternoster Row, pages 843-847
7. Hirsch, Dr., "Medicine: pathologica, practical and therapeutical: On Thymic Asthma: The British and Foreign Medical Review, Edited by John Forbes and John Conolly, Volume II,  April-October, 1836, 1836,  London, Sherwood, Gilbert and Piper, Paternoster Rowepages 237-240
8. Andran, G., Dr., notes in the margins, "A treaties on Diseases of the Chest," by Rene Laennec, translated by John Forbes, 1838, New York, Philadelphia, Samual S. and William Wood, Thomas Cowperthwaite and Co.

RT Cave Facebook Page
RT Cave on Twitter

1874: Solis Cohen recommends tracheotomies for croup

While physicians of the 18th and 19th century were frequently afraid to perform the procedure of tracheotomy, a few physicians, such as Dr. Armand Trousseau, Dr. J. Soles Cohen, and Dr. Morrel Mackenzie strongly recommended that every physicians become adept at the practice, as it is sometimes the only means of saving the life of a child who is suffocating daue to croup.

Mackenzie, a nose and throat specialist , said the first person to recommend the operation of tracheotomy for croup was Francis Home, who published a book on the subject in 1765 called "An Inquiry into the nature, cause and cure of croup." (1, pages 134, 523)

He said various other physicians followed suit, including doctors Crawford, Chaussier, Schwilgue, and others.  (1, page 523)

Trousseau (1801-1867) was an ardent supporter of the procedure, and his thoughts on the subject were often referenced by Cohen as he attempted, in his 1874 book "Croup, in its relations to tracheotomy," to convince his colleagues the procedure was sometimes necessary, and that every physician should become adept in performing the operation.

The procedure had been performed many times in the ancient world, although with great difficulty and risk.  Cohen said it wasn't until 1782 that the first successful tracheotomy for croup was performed, and this way by John Landree in London, and later by Chevalier in London in 1814.  (2, page 7-8)

He said Bretonneau also performed a successful tracheotomy for croup in 1825, yet that was only after two unsuccessful attempts in 1818 and 1820. Professor Stolz succeeded in 1825, and Armand Trousseau in 1833. (2, page 7-8)

Trousseau, Cohen said, "remained the most zealous advocate of the operation during his entire life." (2, page 7-8)

Cohen also explained that successful tracheotomies were rare prior to the 1850s, and the main reason for a rise in success rates was improved care during the procedure, which was mainly due to a new idea called the germ theory of disease.
Post operative deaths declined slightly due to increased attention paid to these patients following the operation.  (2, page 8)

Cohen went on to note statistics comprised by various studies performed that resulted in increased confidence in performing the procedure. (2, pages 8-26)

It should be noted, however, that during this time in our history it was rare for a patient to visit a physician in a controlled setting.  In most instances, when a person was sick, a physician was sent for, and he rode in on his horse and buggy to take care of his patient.

So it was very rare for the operation of tracheotomy, or any operation for that matter, to take place in a controlled setting.  If efforts to control infection were made, it was solely the responsibility of the physician.  One could imagine that, upon observing a young child who was suffocating due to a swollen throat, that a physician would have little time to consider aseptic procedure.

Despite this fact, Cohen said a patient would be more likely to survive such an operation at home than in a hospital.  Cohen said that...

...hospital cases in themselves, as a rule, offer less chance of recovery than cases in private practice, though the operation is frequently performed better, and the after-treatment is much more assiduous." (2, page 8)

A common cause of distress among children, and a common cause for the airway to become swollen and cause suffocation, was croup.  By this age there was a lot known about this disease, particularly that it was inflammation of the throat that can occur as a result of diseases like diptheria.  (2, page 27)

Cohen recommended, that upon visualizing a child, or adult, with croup, that an immediate assessment be made, and the decision to perform a tracheotomy should only be made "whenever it is apparent that death from suffocation cannot be averted by any other means."  (2, page 27)

In other words: tracheotomy should only be used as a last resort to save a life.

The procedure involved the physicians cutting the throat with a blade.  It would have been distressing for all involved, and very painful for the child.  It would have required the parents, and anyone else in the room, holding the child still. It would not have been a pretty site to behold.

When the child was screaming, writhing and turning during the procedure, this increased the risk that the physician would make an incision in the wrong spot. This could cause extreme agony, although it could also increase the risk of death.

For this reason, when the procedure was performed in Great Britain, Germany and the United States, chloroform was would be used as an anaesthetic.  The physician would be well versed in how to obtain it, how to store it, and how to provide it to a patient.  In the case of a screaming child, he would use it liberally, although never in an amount that would risk the child dying as a result of the poison.  (2, page 34)

If you lived in France, however, and you were the poor child suffering, your physician would not provide you with an anaesthetic.  Surely the drug was good for calming a child down, but if given in too high amounts this would cause breathing to become so shallow that asphyxia sometimes occurred, resulting in brain injuries and death.  (2, page 34)

This was especially a concern because there were no standard doses, and it was particularly difficult for a physician to accurately dose a small child.  When not enough was given, the child would continue to fight.  However, when too much was given, the risks were too severe for French physicians to recommend the poison.  (2, page 34)

Regardless of the option to use Chloroform, many physicians were slow to use it, and slow to perform the procedure of tracheotomy, because there was always the hope that other methods would work.  The dilemma of where to draw the line, and when to perform the procedure, continued to plague physicians.  Cohen said: (2, page 5)

Tracheotomy for croup is generally regarded with much disfavor in this city. Its results in Philadelphia have been less encouraging than almost anywhere else; probably because, as a rule, the operation is postponed too long; possibly because our medicinal treatment of croup cures a number of cases which, under less efficient management, would become subjects for tracheotomy; but, whatever the cause, the results, in the comparatively few instances in which the operation has been performed, have been so disheartening, that many practitioners refuse to sanction tracheotomy in croup under any circumstances. This radical feeling is wrong. Not only should our individual experience be utilized in judgment, but the recorded experience of others also. Early failures may be followed by ultimate successes. (2, page 5)

To encourage physicians to use the procedure when needed, he provided statistics. He said: :

Barthez, in a letter to Eilliet on the comparative results of the treatment of croup by tracheotomy and by medication during the years 1854-1858, stated that the first year the Hospital Sainte-Eugenie was opened, 13 croup patients were submitted to tracheotomy, of whom the first died during the operation, and 11 others in succession after the operation; the first recovery taking place in the thirteenth case. Yet Barthez had many successes afterwards; for in a letter published in 1868, he stated that in the same hospital, between the years 1861-1867, 785 cases were operated upon, with 222 recoveries. Guersant lost his first 23 cases, between 1834-1841 ; but after that saved 17 out of 82.

He also referred to statistics by  Armand Trousseau, a 19th century physician who strongly recommended the procedure.  Cohen said:

Trousseau, up to 1842, had operated 119 times, with but 25 recoveries; but at a later date (1854) he reported 222 operations with 127 recoveries. Similar examples of early want of success followed by results truly gratifying are on record. But there have been results even worse than these. Thus Trousseau, in a discussion on tracheotomy in croup, before the Academy of Medicine, in 1858, mentioned, that in the earlier days of the operation, Gosselin, Deguise, Huguier, Jarjavay, and Monod, Jr., of Paris, performed 95 operations successively without a single recovery; that Alphonse Guerin, Mtchon, Laugier, Robert, Nelaton, Lenoir, and Depaul saved but 11 cases out of 117 operations; and Velpeau, Jobert, and Desormeaux but 16 out of 84. He attributed much of this want of success to the idea then prevalent that the surgeon's duty ended when he had opened the trachea. (2, page 5-6)

Trousseau, therefore, recommended that the physician should continue to care for the patient long after the operation was performed.  If he was unable to attend the patient after the operation, it was his job to educate those would were, particularly parents, spouses, relatives, or friends who would be taking care of the patient.

Despite the risks, despite the fears of the physician, despite the anger of parents who watched as their children had their throats cut open, Trousseau recommended that the physician should not be afraid to use the procedure to save a life, and lack of skill and fear was no excuse to evade the procedure.

He strongly recommended that every physician become educated about the proper methods of performing the procedure, and to then to perform it whenever a need arose.  Since practice makes perfect, he suggested that the more a physician performed the procedure the better he would become capable of performing it. The statistics he offered in his book were used to prove it.

Cohen said:

That tracheotomy saves many croup-patients from death otherwise inevitable, and that, too, even under unfavorable circumstances, there has long been no reason to doubt: there is little doubt, either, that patients are occasionally tracheotomized unnecessarily; but the proportionately small number of such instances, whether errors of judgment or errors of prudence, is, in all probability, insignificant in comparison with the number of patients saved by the operation from certain death; life being preserved in the one instance, while it is not sacrificed in the other. (2, page 6)

Cohen reminds physicians that tracheotomy is not a cure for croup, and that it is merely a means of postponing death to allow nature, along with the physicians remedies, time to work.  He said:

Tracheotomy, in itself, does not cure croup. It affords a possibility of recovery by postponing, or insures it by averting death. The course of the disease is continued until all its attendant phenomena have undergone evolution. The surgeon's knife merely cuts a path for air to reach the bronchi in quantity sufficient for the requirements of the respiratory process, and saves the muscular force, exhausted in futile efforts at respiration through the glottis. Is it not possible that the freedom of breathing, and consequent conservation of strength, would aid the system to resist the full effects of the development of the disease, in the further production of exudation, or its plastic deposition upon the bronchial mucous membrane? Then the artificial opening affords a better means of escape for the false membrane, whether dispelled by cough or removed by instruments inserted through the wound; it enables a more efficient application of local remedies to retard the congelation of the exudation into membranes or casts; and thus facilitates the discharge of the plastic material by cough. In short, it gives the patient a chance, offered by no other means, to live and fight through the development and decline of the disease. (2, page 6-7)

A cannula was usually inserted into the stoma, and usually the one's used were double lumen. A double lumen was first used by George Martin in 1730, and was modified by Trousseau.  Cohen said it was important to insert the cannula...

...so that the inner tube projects a little beyond the terminal extremity of the outer one, so as to free the latter when the former is removed or inserted. The proximal (the part closest to the patient) extremity of the outer tube should be suspended by movable joints in a perforated plate to be fastened upon the neck by means of tapes or to adjust itself to the movements of the trachea, avoids pressure against the mucous membrane to some extent; and, thus far, prevents ulceration of the trachea; a serious complication which sometimes attends a prolonged use of the tube, though it sometimes occurs within 36 or 48 hours. The size of the tube should be as large as can be conveniently employed without touching the walls of the trachea. Trousseau thinks that the canula should be of larger calibre than the glottis. Others recommend that it should be about as large as the calibre of the cricoid cartilage, which is considerably less than that of the trachea, in some cases much less. By having a number of tubes of graduated sizes the nicety of adjustment may be attained, whatever may be the age of the child; the same sized tube employed promiscuously for all cases, as is the habit, will not always be well adapted to the case in hand. Too short a canula may be coughed outside the trachea, rendering the patient liable to become asphyxiated in a few moments by its pressure externally. Three times an accident of this kind occurred in Trousseau's practice (2, page 48)

According to Mackenzie, Soles-Cohen was among the many physicians of this era who worked to...

...modify the instruments, to improve the method of procedure, to determine the relative merits of the various operations on the air passages, or to lay down more clearly the indications for the performance of these operations." (1, page 523)

So by trial and error, various improvements were made to both the technique used in performing the operation of tracheotomy and in caring for the tracheostomy after the procedure.  The cannula and inner cannula were improved so that by the end of the 19th century the models used were recognizable to those used today.

A few more advancements would be made during the next several decades, and, finally, in the 1940s the procedure would be perfected.

References:

1. Mackenzie, Morrell, "Diseases of the athroat and nose, Volume I, 1880, Philadelphia, Presley Blakiston
2. Cohen, J. Solis, "Croup, in its relation to tracheotomy," 1874, Philadelphia, Lindsay and Blakiston

RT Cave Facebook Page
RT Cave on Twitter

1769: Dr. Rush writes about asthma in children

Benjamin Rush (1745-1813) was a strong 
advocate of bleeding, and surely he 
recommendedit as a remedy for asthma. 
 Even as his practice started to decline
near the end of his career, he still
insisted on prescribing it.   

Benjamin Rush added nothing new to our disease asthma, although by reading what he wrote about the disease we can gather a good idea of what it would have been like to live with asthma during colonial times in the United States, and what would be the treatment if you saw a licensed physician for it.

As a physician he would have seen many adults and children suffer from asthma, especially in an era when there were few physicians in America.  Yet in the summer of 1769 he was called to take care of many children who were afflicted with the disease, some of whom suffocated and died.  This caused him to take this disease seriously, and to form opinions of his own regarding the disease.

Rush was born in Byberry, Pennsylvania, on the eve of Christmas in 1745, to John Rush and Suzanne Hall. His parents emigrated to America from Oxfordshire, England, becoming Quakers and Baptists.   (1, page 3)

His mother had attended boarding school, and so she was well educated for a woman of this era. His father was a farmer, as were most of his ancestors. He died when Benjamin was only six-years-old, and at this time his mother placed him under the care of her brother, Dr. Finley, who became his teacher and advisor. It was by his uncle's influence that Benjamin became interested in medicine. (1, page 4)

Benjamin obtained a bachelor's degree at the college of Philadelphia. He studied under Dr. Redman for four years, and then attended school at Edinburgh where he obtained his medical degree. He then spent several years in Europe studying medicine and science prior to returning to Pennsylvania in 1769, where he opened a private practice and was appointed professor of chemistry at the College of Philadelphia. (2)

From this time on, the following is what he accomplished:

• He became a very popular physician by attending to the poor
• He became very popular for his skills as a professor
• He published the first American textbook on chemistry
• In 1773 he wrote essays for the patriot cause
• In 1776 he was elected to attend the provincial conference to send delegates to the Continental Congress
• He represented Philadelphia as a signer of the Declaration of Independence
• In 1777 he was appointed surgeon general of the middle department of the Continental Army, although he ultimately resigned. 
• When the war looked grim, he surreptitiously campaigned for the removal of George Washington as commander in chief. He was ultimately busted and confronted by Washington, and no longer participated in any activities regarding the war. 
• In 1789 he wrote in favor of adapting the Federal Constitution
• He was elected to the the Pennsylvania Convention, and he voted in support of the Federal Constitution
• He was treasurer of the U.S. Mint from 1797-1813
• He was a proponent for the abolition of slavery
• He petitioned for a national educational system for both men and women
• He petitioned for medical clinics to treat the poor
• He was an advocate for bleeding in medicine, and utilized it for nearly every diagnosis, including asthma. 
• He died April 19, 1813.  He was 68-years-old. 
• Throughout his life, he was the most popular physician in America.  (2)

So not only was he a well respected professor and physician, he was an important founding father; he was an important figure in the establishment of the United States of America.

As far as medicine was concerned he was a strong supporter of the ideas of Dr. Thomas Sydenham, and even went as far to write the introduction to the American edition of Sydenham's book "The works of Thomas Sydenham" that was published in 1808.

As far as our asthma history is concerned, he wrote the following articles:

1. An account of asthma, from an uncommon cause
2. A dissertation on the spasmotic asthma in children
3. An inquiry into the natural history of medicine among the Indians

"A dissertation on the spasmotic asthma in children," was published in the Pennsylvania Gazette in the winter of 1769.  It was basically a letter to Dr. John Millar about an epidemic of asthma that winter. It must have hit him hard to witness so many children suffer, and to watch as some died.   (2, page 1)

He said asthma was not well known among the populace of Pennsylvania, and that even the ancients knew little of it.  It was a condition that was either inflammatory or spasmotic, and usually associated with "particular climates or situations."  (2, pages iii, 2)

He said there were other names for it. The Irish called it the Hives "from the resemblance it bears to a disorder which prevails in Ireland of that name."  (2, page 2)

He said it presented with "difficulty of breathing... and other symptoms of oppression and disorder in the lungs."  Dr. Home of London, who was the first to give an accurate history of it, called it "the Croup, -- or Suffocatio Stridula, -- a name by which it is known in Scotland." (2, page 3)

He mentioned Dr. John Millar, who described an outbreak in England in 1755.  He described it this way:  (2, page 3)

Children at play were sometimes seized, but it generally came on at night; a child who went to bed in perfect health, walked an hour or two afterwards in a fright, with his face much flushed, or sometimes of a livid colour, -- incapable of describing what he flet, -- breathing with much labour, and with a convulsive motion in teh belly, the returns of inspiration and expiration quickly succeeding each other in that particular sonorous manner, which is often observed in hysteric paroxysms.  The child's terror sometimes augmented the disorder.  He clung to the nurse, and if he was not speedily relieved by coughing, belching, sneezing, vomitting, or purging, the suffocation encreased, and he died in the paroxysm. (2, pages 3-4)

He also published a letter from Dr. Haygarth to Dr. Smith, in which Dr. Haygarth said that Dr. Russel was the first to describe convulsive asthma in children in his book De Oeconomia Naturoe.  Dr. Russel is quoted to have written:

A Fever attends this disease with great remissions; but upon every fresh access, the respiration becomes very short and difficult; the child is forced to sit up erect in its bed, or to get up; when it cries, is very hoarse; but often makes, upon every inspiration, a shrill, skreaking, or clangose sound; and is if it is not instantly relieved by nature or art, must die. -- I have seen this distemper carry off, very suddenly, several children in a family. (2, pages 27-28)

Dr. Rush said that it used to be believed that asthma in children was inflammation in the lungs. Yet the theory believed by most physicians was that it "occassioned by a preternatural quantity of phlegm or mucus," said Rush. (2, page 4)

Upon dissecting children who died of the disease, Dr. Home discovered a large quantity of mucus in the trachea and bronchi.  "This opinion," Rush said, "is now pretty universally received by most practitioners, particularly in this part of the world."  (2, page 5)

However, based on his own experiences and observations as a physicians, he did not support this prevailing theory.  He said he witnessed many adults diagnosed with asthma or peripneumony in life who, when an autopsy was performed after death, they had not even the slightest sign of inflammation in the lungs and no evidence of respiratory disease.  (2, page 4)

A three-year-old child was seized with asthma early one morning, and his mother observed all the symptoms of hives: his breathing was difficult, his abdominal muscles were worked hard as he breathed, and pulse was rapid, his skin was warm to the touch and of livid color.  She was also concerned because he was coughing up quite a bit of blood.

So she called for Dr. Rush.

He traveled to the child's home by horse and buggy, and was met at the door by an anxious mother.  He followed her into the house, carrying his worn leather bag, without much as a word, and he saw a girl sitting on the edge of the couch.
Her chest was bare, and her ribs were evidently showing.  The shoulders of the girl were high, and his abdomen was vibrating hard with each inhalation.
Her skin was pale and dusky, and she had a bluish tinge around her lips and finger tips.  He observed all this in the first seconds of being in the same room as the girl.

"I'm sorry to be a bother," the lady wailed, "but I was so concerned for him breathing this way."

"You did right by calling me," he said to the lady to allay her anxiety.

He sat in a chair opposite the girl and set his bag between her legs.  He opened it and rummaged through its contents until he found a small box.  He opened it, exposing various small jars.  He took out one of them and opened the top.

"I need a teaspoon, please," he said nonchalantly.

She rushed into the kitchen and then back with a teaspoon that she handed the physician.  He handed her the bottle, and she poured some of the emetic onto the spoon and gave it to the boy.  Even though the Dr. knew it was of a horrible taste, the girl never winced; a sure sign she was desperate for any remedy.

The mother, who was wearing her pajamas and her hair was ruffled, grabbed a bowl from the shelf and gave it to the girl to use as an emesis basin.  The mother rubbed the girl's back and head as he emptied his stomach contents.  This initially seemed to ease his breathing, but, after twenty minutes of waiting, it seemed to be of no avail.

The doctor then took some small cups from his bag and a candle.  He lit the candle and warmed the cups.  He then had the girl lie on his back, and as he set the first cup upon the girl's chest the boy jumped up.  The mother hugged and consoled the girl, who was now crying vehemently.

"A bath," the doctor said, "A warm bath.  The steam might help."

The doctor sat next to the girl, and tried to sooth him with his words.  He actually thought he got a slight smile from the girl when he said something funny that had happened to him in the morning.  Perhaps, he though, the girl could at least forget his distress.

Right then his mother said, "It's ready."

The doctor helped the girl take off his pants, and carried him to the tub.  He gently set her in.  The boy immediately placed his arms on the side of the tub to lift his shoulders.  She was now struggling hard to breathe.  She was crying now, wailing.

Dr. Rush could feel the steam on his own face, and as he looked at the mother he could barely distinguish her tears from moisture from the steam.  After several moments of watching the girl suffer so, he lifted her from the water and set her back on the couch.  The girl was now unconscious.

The next day, after the funeral at the girl's home, Dr. Rush pulled the mother aside, once again, and gave her a big hug.  "I'm sorry I couldn't help," he said.

"It's okay," she whispered through tears.  "She's in a happy place now."

She introduced the doctor to her husband.  Dr. Rush then garnished the nerve to talk to them about something he had wanted to do for some time.

A few days later he sat in his study to finish working on his book about the disease he just tried to treat.  He wrote: "

As I was uncommonly anxious to see a dissection of a patient that died of this disorder, I prevailed, with some difficulty, with the parents to let me open her. By their particular desire, I called my worthy friend Dr. Duffield, to assist me in this dissection. Upon opening the thorax we found the lungs adhered pretty closely to the left side. this affection, we had reason to believe, was of long standing, from the closeness with which it adhered, and the force it required to separate it from the pleura. Those who are acquainted with the dissections of dead bodies, know that this is no uncommon thing in most of the bodies we meet with. There are few persons that have ever had an inflammation in their lungs or pleura, but what have adhesions of this kind, and yet feel not the least inconvenience from them. The lungs were quite found, nor could we perceive the least appearance of inflammation in them. Uon opening the Trachea, we found no signs of phlegm or hardened mucus in it. This, together with both the Bronchia, appeared in a sound and natural state.  this dissection, together with the arguments we advanced before, serve as irrefragable proofs that the disorder is not occasioned by the causes assigned by Dr. Home, but by some spasmodic affection of the lungs..  (2, pages 10-12)

By this autopsy he confirmed his suspicion that asthma was not inflammatory, and it was not caused by increased phlegm.   Instead, he suspected asthma "to be rather of the nervous or spasmotic," he wrote.  (2, page 7)

His listed the following as evidence:

• "The suddenness with which children are seized with it.  This corresponds with other convulsive disorders we are acquainted with.  Did it depend upon the presence of phlegm in the wind-pipe, the disorder would come on more gradually; for the accumulation of this phlegm is certainly gradual."  (2, page 8)
• "The disease in many cases is periodical.  This too corresponds with nervous diseases." It appears only at night, or at certain times of the day.  "If the disorder depended upon phlegm, it would certanly be more uniform in its effects, for we know that same causes will always (caeteris paribus)produce the same effects." (2, pages 8-9)
• "We often see patients in this disorder relieved by nervous medicines.  The warm bath has sometimes given immediate relief, when they have appeared to be in the very jaws of death.  It seldom fails of affording a temporary relief.  Opium, we all know, is a powerful antispasmodic medicine. An ingenious physician in New-York, informed me, that he makes it a constant practice to give small quantities of thebaic tincture, joined with oxymel of squills, in the Hives, after giving a puke or two, and that he had seldom found it fail to succeed." (2, page 9-10)
• The fact that the disease does not dissipate after the expectoration of phlegm is evidence that it is not caused by phlegm.   (2, page 10)

While he believed that asthma was spasmotic and nervous in both children and adults, that is where the similarities end.  He said:

Besides this, do we not perceive a considerable  resemblance between this disorder and the asthma in adults?  erhaps they difer from each other only in degree.  Now that asthma has always been supposed to be occasioned by a spasm upon the extremities of the Bronchia. (2, page 14)

(To view a case of adult asthma described by Dr. Rush, click here. It's only about four pages, and the words are big, so it should be a quick read.  Just remember that in many books printed in the 18th century many of the s's are replaced with f's, so this can make reading a little tricky, but not impossible.)

So, if you brought your child in to see Dr. Rush, and he diagnosed your child with asthma, what are the remedies that he might have used?  I will list them here:

1. Bleeding: "Bleeding is generally ordered in the first stage of the disease.  It may act by taking off the tension and fullness from the vessels, which tend greatly to keep up the spasm. I am far, however, from thinking it of so much importance as some have imagined. The disorder, we have proved, is not of the inflammatory kind.  Bleeding therefore, in some cases, I believe, has done more harm than good."  (I just want to remind my readers here that inflammation in this era was considered congestion of blood in the vessels that could be remedied by removing some of this blood, hence the use of bleeding was often recommended. The procedure would be performed with the use of the lancet.  Pneumonia, apoplexy, rheumatism, and hydropsy are just a few examples of a disease considered to be caused by inflammation.) (2, pages 18-19)
2. Vomits (emetics):  "Our chief dependence should be placed on these.  They may be given at all times of the disorder.  What vomits should we prefer?  It is a matter of little consequence which of them we use, provided we give them strong enough. the antimonial vomits are the surest, and most to be depended upon.  In the cases I have been called to, I have always given small doses of tartar emetic.  Some I know join calomel with vomits.  I cannot say I ever saw it do any service, and I believe few practitioners would venture to depend upon it alone.  Others join ipecacoana with the tartar emetic.  I cannot tell upon what this practice is founded." (2, pages 19-20)
3. Warm bath:  "This w know is of singular use in all spasmodic disorders.  I have seen it in one or two cases afford immediate relief, and I have heard of several cases, in which it has saved the lives of patients, apparently in the agonies of death."  (2, page 21)
4. Blisters:  "Blisters are justly ranked among the most powerful antispasmodics... It is a much better practice to apply the blisters directly to the breast, than between the shoulders." (2, page 21-22) 
5. Bronchotomy (tracheostomy): While other physicians have performed the procedure in croup with some success, Dr. Rush did not recommend it.  (2, pages 24-25)
6. Antispasmotics: Such as musk, camphor and opium may have an affect on the disease.  Dr. Rush said he used it a few times with success, although he had no evidence that it was a truly effective remedy for this disorder. (2, page 25-26)
7. Other:  "Every attempt to lessen the number, or mitigate the violence, of diseases in children, is laudable, especially in a young country, like this, where the population is so much to be desired.   (2, page 26)

So Benjamin Rush was an essential figure in the creation of a new nation.  In a era when there were few physicians, Rush presented the residence of Pennsylvania with a solid option of obtaining medical advice and treatment.

And even thought the disease Dr. Rush described here is probably croup and not asthma, we can gather a good idea of how you would be treated by him if you requested his services to treat your asthma.

Note: In reviewing Dr. Rush's letter, I think it can be quite certain that the disease that Dr. Rush was describing here was not asthma, but croup. It makes sense that he would confuse the two diseases, as they often display similar symptoms. According to Alyn Brodsky, Hives was another way of describing a condition called Heaves, which was a description of the forceful act of children inflicted with this disease trying to inhale and exhale. (5, page 94)

References: 

1. Good, Harry G., "Benjamin Rush and his services to American education," 1918, witness press
2. Benjamin Rush, http://www.ushistory.org/declaration/signers/rush.htm, accessed 1/3/14
3. Rush, Banjamin, "A dissertation on the spasmotic asthma of children: in a letter to Dr. Millar, 1770, London, printed for T. Caddell, and D. Wilson and G. Nicoli, Eighteenth Century Collection Online Print Editions, originally published in October of 1769 in the Pennsylvania Journal.  According to It was one of the first medical publications published in the American colonies. 
4. Rush, Benjamin, "An account of asthma, from an uncommon cause, Medical Observations and Inquiries, volume 5, London, as published in the book "Medical and philosophical commentaries,"1776, volume 4, pare 1, by a society in Edinburgh, London, pages 198-202, as 
5. Brodsky,Alyn, "Benjamin Rush: Patriot and Physician," 2004, New York, St. Martin's Press

RT Cave Facebook Page
RT Cave on Twitter