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

1878: Thorowgood supports Salter's asthma theories

Dr. John Charles Thorowgood wrote a book called "Notes on Asthma" that went through a variety of editions.  Probably due to a wave of new evidence learned about the disease, the later editions were called "Asthma and Chronic Bronchitis, which sheds light for historians on the evidence clearly separating these two diseases.

Thorowgood's basic description of asthma is not far removed from the theories postulated by Dr. Henry Hyde Salter, that: (1, page 1-2)(2, page 16)

1. The main component of an asthma attack is spasms of the unstriped contractible fibres (bronchial muscles) that wrap around the bronchi that results in narrowing of these air passages
2. That the main cause of such spasming is due to a nervous disorder, as can be confirmed by autopsy when an asthmatic dies: no lung scarring can be found.  This lack of any evidence of disease clearly indicates asthma is nervous in origin.  There are two routes the nerves can cause asthma:
• Central Nervous System: Some exciting cause, probably emotional, triggers the asthmatic response, and causes narrowed air passages. 
• Reflex Action: Something stimulates the vagus nerve or pneumogastric nerve, such as overeating, forced expiration (coughing or laughing)

He also agrees with other physicians of his era, Salter included, when he writes the following: (1, page 2)(2, page 16)

During the intervals between his attacks the patient probably enjoys fair health, and, as a rule, lives to a good age; should he, however, be cut off prematurely by death, what do we find as the morbid anatomy to explain the wellmarked symptoms seen during life?

In other words, he believes that pure asthma is intermittent in nature, allows the patient to live a relatively normal life between attacks, and that asthma rarely causes death.  In the rare cases asthma does cause death, the asthma is not pure: it is associated with some type of morbid condition such as chronic bronchitis or heart failure.

He describes an attack this way: (1, page 2)(2, page 16)

He defines asthma as symptoms "distressing enough to endure or to witness; and yet, when things seem to be at their worse, and the patient well-nigh at his last gasp, a remission comes on, the spasm yields, air enters the lungs, and the attack subsides, coincidentally often with access of cough and mucous expectoration." 

He likewise agrees with Salter that while pure asthma may present with no structural changes, that after years of repeated and violent attacks, "cannot but lead to some alteration of tissue, and the microscope will probably show some granular or fatty degeneration in the air cells of the lungs, though to the naked eye appearances may be normal." (1, page 3)(2, page 17)

So in the rare event someone does die from asthma, it will be due to some form of organic changes that take place after years of asthma attacks.  Either that, or it was some organic change, such as occurs with chronic bronchitis and heart failure, caused the asthma and ultimately lead to that person's death.  (2, page 17-18)

These are things that both Salter and Thorowgood agree upon.

References:

1. Thorowgood, John C., "Notes on Asthma," 1878, 3rd edition, London, J & A Churchill
2. Thorowgood, John C., "Asthma and Chronic Bronchitis: A New Edition of Notes on Asthma and Bronchial Asthma," 1894, London, Bailliere, Tyndall, & Cox

1873: Lebert creates new asthma theory

Herman Lebert (1813-1878)

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

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

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

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

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

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

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

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

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

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

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

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

References: 

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

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1870: Bert's experiments advance respiratory wisdom

Paul Bert (1833-1886)

"It can be said of Paul Bert as it has been of Vesalius, Harvey and Boyle, that the full significance of his work could not be fully appreciated until long after his death." (8, page v)

This was a quote from John F. Fulton, who wrote the forward to the 1843 edition of Bert's book "Barometric Pressure."

Bert's experiments would have a broad and lasting impact on surgery, aviation, mountain climbing, deep sea excursions, mining, pressure breathing machines, and even the definition of asthma.

He was born in Auxerre, France, on October 17, 1833, attended school in Paris, and received his medical degree in 1863. (2)(8, page V)

Fulton said that while in Paris he was assistant to Dr. Claude Bernard in his laboratory.  Fulton said "Bernard recognized his ingenious mind and predicted a brilliant future." (8, page VI)

Denis Jourdanet (1815-1892)

His thesis on grafting of animal tissue gained him public acclaim, and this helped him to quickly earn fame in the medical community. (2)(8, page VI)

Animal grafting, and later skin grafting, was "an operation consisting of the removal of a living part and transplanting it so that it shall continue to live on another part of the same individual or on another individual," said the authors of an 1888 biography of Dr. Bert in Popular Science Monthly.(2)(8, page V)

In 1865, the Academy of Sciences awarded him a prize in experimental physiology for his work on animal grafting and skin grafting.  This work was significant because it allowed physicians to perform plastic surgery on soldiers injured during the war of 1870.  (2)(5, page ?)(8, page V-VI)

In 1867 he was appointed to a chair in the Faculty of Sciences at Bordeaux where he taught zoology.  Then he became Bernard's successor in December of 1869 when he was named Professor of Physiology at the Faculty of Sciences in Paris. (2)(8, page VI)(13, page 599)

In 1870 Bert became interested in respiratory disorders, such as asthma, chronic bronchitis, and emphysema.  He performed experiments to learn more about these diseases, and to find methods of helping people with these diseases.   (1, page 194)(8, page VII)

In 1854 Alton Wintrich performed experiments that seemed to disprove the spasmotic theory of asthma in favor of the diaphragmatic theory of asthma.  For 16 years Wintrich gained many followers.  But Bert aimed to prove him wrong.

In 1870 he attempted, with improved methods of scientific research compared to that used by Williams and Longet, to stimulate the vagi of dogs.  As he expected, this indeed produced dyspnea.  His experiment reaffirmed for the medical community the spasmotic theory of asthma.   (10, page 10)(11, page 37)(12, pages 5-6)(13, page 16)(14, page 599)

According to W.H. Geddings in 1885, along with demonstrating that respiration could be "arrested by irritation of the pneumogastri (vagi)," it could also be arrested by irritation of the "laryngeal nerves or the Schneiderian membrane of the nose (membrane lining the maxillary sinus cavity)." (1, page 194)

In 1855, Ludwig Traube came to a similar conclusion.

Bert's experiment was important because it prevented physicians from spending what minimal time and money was dedicated to asthma form being wasted on areas that were already disproved.

Around this time, said Fulton, a friend of his, Dr. Denis Jourdanet, had just returned from an excursion to Mexico where he had spent time in the mountains at great heights and suffered mountain sickness.  The two decided that Bert should dedicate his time performing experiments on the effects of pressure on plants, animals and humans. Jourdanet was a wealthy man, and he offered to provide any funds that Bert needed. (8, page VII)

Bert's first experiment was performed on April 15, 1874.  He sent three balloon enthusiasts and equipment in a hot air balloon called Zenith.  The mission was to collect data from the the upper atmosphere.  Another goal, however, was to exceed 24,000 feet, which was the height accomplished by an English balloonist named Glaisher in 1862.

At 26,000 feet all of the men were unconscious.  Upon the Zenith's return to the earth, two of the men had perished, and the third was insensible.  Bert hypothesized the reason was due to lack of oxygen to the brain (2)(5, page 112)(8, page VII)

This was a set back for Bert in which none of the equipment, and obviously none of the men, were able to function at that height due to cold and rarified (negative pressure, suction) air.  Most of the equipment was also damaged in the efforts made to get the balloon back down to earth, so no data could have been obtained anyway.  (2)(5, page 112)(8, page VII)

While this was a set back, it did not keep him from marching forward.  Instead of using humans to perform his studies from here on out, he did them in his laboratory using small animals.  Only when perfected his experiments did he resort to using humans.  (2)(5, page 112)(8, page VII)

The first order of business for Bert was to invent a device for measuring pressure and put together compression chambers.  He used a smaller compression chamber for small animals, and a larger one for himself and his friends.  (see figures)(2)(8, page VI)

In a laboratory experiment Bert placed a sparrow in the compression chamber made of pneumatic glass bells and exposed it to low pressures.  When it started to suffer he administered oxygen, at which point the bird "at once became himself again."  Upon this success, he performed the same experiment on himself, and he observed at higher pressures that his heart would beat faster and he'd have palpitations.  At one point he wanted to write in his tablet, but could not.  When he inhaled oxygen these symptoms went away. (7)

By these experiments he concluded that the lower the atmospheric pressure (as what would occur with high altitudes) results in oxygen tensions in the air and blood too low to support life. Instead of inhaling 21% oxygen which is present in normal room air, he was inhaling a lower percentage of oxygen.  (7)

High altitudes, or high atmospheric pressures, subject humans to the risk of suffocation or asphyxia. Early symptoms are increased heart rate,weakness, malaise, nausea, and vomiting. The colder the air the earlier these symptoms appear. For instance, the symptoms appear earlier in the Alps than in the Himalaya, Bert said. (7)

The remedy here would be "the respiration of an air sufficiently rich in oxygen to maintain the tension of that gas at its normal value." (2)

In another laboratory experiment Bert placed a sparrow in the compression chamber made of pneumatic glass bells and exposed it to high pressures (compression).  He then decompressed the bird rapidly to atmospheric pressure, at which time the bird suddenly died.  Upon inspection of the body he found air bubbles in the arteries and heart.  The same effect resulted during similar experiments performed with rats and small dogs. (5, page 115)

Robert Boyl had observed bubbles in the eyes of a snake he placed in a compression tank he invented, although no further investigations were made at that time into the nature or cause of the bubbles.  Bert, however, benefited from improved laboratory equipment.  (5, page 116)

Bert concluded that higher atmospheric pressures (as what would occur as one travels deeper under water) result in increased oxygen tensions in the air and blood.  The remedy here would be avoidance of too high a pressure (such as greater than 5-6 atmospheres), and gradual decompression back to atmospheric pressure (1 atmosphere). (2)

He observed that the effects of high pressures may kill not only humans and animals, but plants too.  (2)

While the significance of this work may not have been immediately known, the value of it was immediately recognized by the scientific community.  For this work the Academy of Sciences awarded him a prize of twenty thousand francs. (2)

His experiments would have an impact in many areas of science and medicine.

His conclusions about the effects of diminished pressure resulted in equipment, such as oxygen tanks and masks that made aviation possible.  For this reason, he is often referred to as the father of aviation medicine.

Improved methods of storing and delivering oxygen was also thought to benefit people with respiratory disorders, and so research was eventually done in this regard, some of it by Bert himself.

His conclusions about the effects of increased pressure resulted in better knowledge of decompression sickness or bends.

Bends occurs when a person moves from deep water (where the pressure is higher) to the surface (where the pressure is lower) too fast.  This causes bubbles to escape into the blood and tissues, and can cause symptoms such as headache, joint pain, nose bleeding, vertigo, shortness of breath, nausea, vomiting, and sometimes death.

This is a small compression chamber made of a pneumatic glass jar.
Bert was able to use it to expose a sparrow to low pressures.
He reduced the pressure using a manometric tube,
observing at what point the bird started to suffer.
He used the India rubber bag to administer oxygen to the bird,
and "at once the bird becomes himself again," he wrote.
He concluded that at high altitudes, where the pressure was low,
: "it appears it is not the lowering of mechanical pressure
that produces the symptoms, but the low tension of oxygen
of the dilated air, which low tension prevents the oxygen from
entering the blood in sufficient quantity." (7)

So Bert became interested in helping people with breathing difficulties during the early 1870s.  He said it was already known (such as by the works of Tavarie) that compressed air (higher pressure) helped people with anemia, chronic bronchitis, and emphysematous asthma. The result was easier breathing, and a lower heart rate. (7)(8 page VII)

Improved knowledge of the effects of high pressure on the human body resulted in Bert, and various other physicians, trying to invent machines that would adjust the pressure of inspired air to relieve the feeling of air hunger. Such machines would be experimented on patients of various lung disorders, including asthma.

In fact, in his 1877 article "Atmospheric pressure and life," Bert said:

The great influence that may be exerted upon living beings by atmospheric pressure is now questioned by none, and there is even a disposition to exaggerate its importance. If the barometric column rises or falls a few millimetres, nervous people affected with the asthma perceive phenomena, whether of a beneficial or of a noxious kind, which they do not hesitate to attribute to the weight or to the lightness of the atmosphere. But if this were the only cause of their sensations, then they should experience the same symptoms whenever they subject themselves to equal variations of pressure, as in passing from the level of the sea to a point only a few feet above it, or vice versa. (7)

In his 1878 book "Barometric Pressure," he published the results of his experiments on barometric pressure. He dedicated the book to his friend, and the man who funded the project, Dr. Jourdanet.

This is a compression chamber that allowed Bert to measure
the effects of barometric pressure on himself and others.
Inside was an Indian rubber bag so he could inhale oxygen.
Access points allowed him to take blood samples
to determine changes in blood oxygen tensions.
He exposed himself to decreased pressures.  Once he
started to feel symptoms he inhaled oxygen.  He wrote:
"But all these symptoms disappeared as by enchantment
so soon as I respired some of the oxygen in the bag;
returning, however, when I again breathed the air in
the cylinder."  (7) 

There would be many devices invented, and many failed experiments, over the next hundred years, before a truly effective, and mass producible, device would be invented to truly help patient's with respiratory disorders.  Yet it was Bert's work that got it all started.

He also performed work using anesthetics such as chloroform, and to administer it he devised an apparatus that allowed the patient to inhale an ideal percentage of the compound.   (2)(3, page 427)

Along with being a successful physician and scientist, he was also a successful politician.

As Bert was performing his experiments on pressure,
he started to wonder how the world was created.
In regards to animals dying due to compression, he wrote:
"Thus it is the oxygen that is to blame.  Oxygen at too high
a tension destroys animal life.  Long I hesitated to characterize
as a poison the 'nursing father' of everything that lives, but there
was no help for it.  Oxygen, which gives us life, slays also,
when administered in too strong a dose.  I have had to study
thoroughly this paradoxal poison to determine the different
effects of varying doses, and its action upon our tissues. (7)

So after Williams, Longet and Bert all performed experiments to prove the spasmotic theory of asthma, you probably thought the subject was settled.  Well, not quite. There still remained skeptics with credible arguments against it.

J.B. Berkart, in his 1878 book "On Asthma," explained that, during his work on asthma, Bert had a difficult time getting the air passages to contract until he realized that he had been over inflating the lungs.

Berkart said it was only when he provided less inflation that he was finally able to induce the air passages to...

"contract... upon electrical irritation, applied either directly to it or to the pneumogastric nerve.  But the contractions were so feeble and slow as to induce Bert to think that they had no active share in the mechanism of respiration.  Moreover, the paralysis of the bronchial muscles, following the section of the vagus, did not appear to influence in that least the function of nutrition of the lungs.  Thus the integrity of those muscles, not being indispensable to an efficient ventilation of the lungs, it seemed not unreasonable to conclude that their spasmodic contractions could hardly have the effect generally assigned to them."  (4, page 42-43)(9,page 5)

Berkart said that Bert's experiments did not initially demonstrate contraction of the lungs because he over inflated them.

Berkart believed that Bert's experiments demonstrated proof that the air passages may constrict as Williams proved, but this did not occur in asthma because most asthmatics also present with emphysema, which is essentially over inflation of the lungs.  (4, page 103)

Berkart's theory was respected among the medical community, although it did not have a long lasting influence.

In 1886 Bert was appointed governor-general of Tonquin, and soon thereafter his health started to fail.  On a return to France during the year he gave a farewell speech at a meeting of the Academy of sciences, supposedly because he knew he was ill. He died of dysentry on November, 11, 1886. (2)

References:

1. Geddings, W.H., author of the chapter on "Bronchial Asthma," in the book  "A System of Practical Medicine," edited by William Pepper and Louis Star,Volume 3, 1885, Philadelphia, Lea Brothers and Co.
2. "Sketch of Paul Bert," Popular Science Monthly," July, 1888, Volume 33, compliments of wikisource.org, http://en.wikisource.org/wiki/Popular_Science_Monthly/Volume_33/July_1888/Sketch_of_Paul_Bert, accessed 2/6/14
3. Waller, A., "Meeting of the society of Anaesthetists: Dosage in Anaesthetics," The Clinical Journal, April 6, 1898, pages 426-430, volume XI, October 27- April 20, 1898, Sixth Year, Edited by L. Eliot Creasy, 1898, London, The Medical Publishing Company
4. Berkart, J.B., "On Asthma: It's pathology and treatment," 1878, London, J. & A. Churchill
5. Phillips, John L., "The Bends," 1998, Yale University
6. Tissier,Paul Lewis Alexandre, edited by Solomon Solis Cohen, "Pneumotherapy: Including Aerotherapy and inhalation methods," volume X, 1903, Philadelphia, P. Blakiston's Sons and Co., pages 296-224.  If the profession of respiratory therapy existed in their era, we would be reading their books.  However, as it was, their books were written for the medical profession. All of the material from this post is from Tissier's book unless otherwise noted in the above paragraphs. Tissier page 72
7. Bert, Paul,  "Atmospheric pressure and life," Translated from the French by J. Fitzgerald, Popular Science Monthy, July, 1877, volume 11, http://en.wikisource.org/wiki/Popular_Science_Monthly/Volume_11/July_1877/Atmospheric_Pressure_and_Life, accessed 2/8/14
8. Fulton, John F., author of the Forward to Paul Bert's book "Barometric Pressure," 1843, Columbus, Ohio, The F. J. Heer Printing Company
9. Bert, Paul,  "Barometric Pressure," 1843, Columbus, Ohio, The F. J. Heer Printing Company
10. Dobell, Horace, "On Asthma: It's nature and treatment," 1886, London, Smith, Elder and Co
11. Brown, Orville Harry, "Asthma, presenting an exposition of nonpassive expiration theory," 1917, St. Louis, C.V. Mosby Company
12. Thorowgood, John Charles, "Notes on Asthma," 1878, 3rd edition, London, J and A Churchill
13. Thowowgood, John Charles, "The Lettsomian Lectures: delivered at the Medical Society of London, 1879, on bronchial asthma: it's causes, pathology and treatment," 1879, London, Bailliere, Tindall, and Cox
14. West, Samuel Hatch, "Diseases of the organs of respiration," volume II, 1902, London, Charles Griffin & Company, Limited 

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1870: Biermer proves spasmotic theory once and for all

Michael Anton Biermer (1827-1892)

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

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

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

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

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

Thorowgood said:

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

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

References:

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

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1870: Bert's experiments help anyone with respiratory ailments

Paul Bert (1833-1886)

"It can be said of Paul Bert as it has been of Vesalius, Harvey and Boyle, that the full significance of his work could not be fully appreciated until long after his death." (8, page v)

This was a quote from John F. Fulton, who wrote the forward to the 1843 edition of Paul Bert's book "Barometric Pressure."

Bert's experiments would have a broad and lasting impact on surgery, aviation, mountain climbing, deep sea excursions, mining, pressure breathing machines, and even the definition of asthma.

He was born in Auxerre, France, on October 17, 1833, attended school in Paris, and received his medical degree in 1863. (2)(8, page V)

Fulton said that while in Paris he was assistant to Dr. Claude Bernard in his laboratory. Fulton said "Bernard recognized his ingenious mind and predicted a brilliant future." (8, page VI)

Denis Jourdanet (1815-1892)

His thesis on grafting of animal tissue gained him public acclaim, and this helped him to quickly earn fame in the medical community. (2)(8, page VI)

Animal grafting, and later skin grafting, was "an operation consisting of the removal of a living part and transplanting it so that it shall continue to live on another part of the same individual or on another individual," said the authors of an 1888 biography of Dr. Bert in Popular Science Monthly.(2)(8, page V)

In 1865, the Academy of Sciences awarded him a prize in experimental physiology for his work on animal grafting and skin grafting.  This work was significant because it allowed physicians to perform plastic surgery on soldiers injured during the war of 1870.  (2)(5, page ?)(8, page V-VI)

In 1867 he was appointed to a chair in the Faculty of Sciences at Bordeaux where he taught zoology. Then he became Bernard's successor in December of 1869 when he was named Professor of Physiology at the Faculty of Sciences in Paris. (2)(8, page VI)(13, page 599)

In 1870 Bert became interested in respiratory disorders, such as asthma, chronic bronchitis, and emphysema.  He performed experiments to learn more about these diseases, and to find methods of helping people suffering from them.   (1, page 194)(8, page VII)

In 1854 Alton Wintrich performed experiments that seemed to disprove the spasmotic theory of asthma in favor of the diaphragmatic theory of asthma. For 16 years Wintrich gained many followers. But Bert aimed to prove him wrong.

In 1870 Bert attempted, with improved methods of scientific research compared to that used by Williams and Longet, to stimulate the vagi of dogs. As he expected, this indeed produced dyspnea. His experiment reaffirmed for the medical community the spasmotic theory of asthma. (10, page 10)(11, page 37)(12, pages 5-6)(13, page 16)(14, page 599)

According to W.H. Geddings in 1885, along with demonstrating that respiration could be "arrested by irritation of the pneumogastri (vagi)," it could also be arrested by irritation of the "laryngeal nerves or the Schneiderian membrane of the nose (membrane lining the maxillary sinus cavity)." (1, page 194)

In 1855, Ludwig Traube came to a similar conclusion.

Bert's experiment was important because it prevented physicians from spending what minimal time and money was dedicated to asthma form being wasted on areas that were already disproved.

Around this time, said Fulton, a friend of his, Dr. Denis Jourdanet, had just returned from an excursion to Mexico where he had spent time in the mountains at great heights and suffered mountain sickness. The two decided that Bert should dedicate his time performing experiments on the effects of pressure on plants, animals and humans. Jourdanet was a wealthy man, and he offered to provide any funds that Bert needed. (8, page VII)

Bert's first experiment was performed on April 15, 1874. He sent three balloon enthusiasts and equipment in a hot air balloon called Zenith. The mission was to collect data from the the upper atmosphere. Another goal, however, was to exceed 24,000 feet, which was the height accomplished by an English balloonist named Glaisher in 1862.

At 26,000 feet all of the men were unconscious. Upon the Zenith's return to the earth, two of the men had perished, and the third was insensible. Bert hypothesized the reason was due to lack of oxygen to the brain (2)(5, page 112)(8, page VII)

This was a set back for Bert in which none of the equipment, and obviously none of the men, were able to function at that height due to cold and rarified air. Most of the equipment was also damaged in the efforts made to get the balloon back down to earth, so no data could have been obtained anyway. (2)(5, page 112)(8, page VII)

While this was a set back, it did not keep him from marching forward. Instead of using humans to perform his studies from here on our, he did them in his laboratory using small animals. Only when perfected his experiments did he resort to using humans. (2)(5, page 112)(8, page VII)

The first order of business for Bert was to invent a device for measuring pressure and put together compression chambers. He used a smaller compression chamber for small animals, and a larger one for himself and his friends. (see figures)(2)(8, page VI)

In a laboratory experiment Bert placed a sparrow in the compression chamber made of pneumatic glass bells and exposed it to low pressures. When it started to suffer he administered oxygen, at which point the bird "at once became himself again." Upon this success, he performed the same experiment on himself, and he observed at higher pressures that his heart would beat faster and he'd have palpitations. At one point he wanted to write in his tablet, but could not. When he inhaled oxygen these symptoms went away. (7)

By these experiments he concluded that the lower the atmospheric pressure (as what would occur with high altitudes) results in oxygen tensions in the air and blood too low to support life. Instead of inhaling 21% oxygen which is present in normal room air, he was inhaling a lower percentage of oxygen.  (7)

High altitudes, or high atmospheric pressures, subject humans to the risk of suffocation or asphyxia. Early symptoms are increased heart rate,weakness, malaise, nausea, and vomiting. The colder the air the earlier these symptoms appear. For instance, the symptoms appear earlier in earlier in the Alps than in the Himalaya, Bert said. (7)

The remedy here would be "the respiration of an air sufficiently rich in oxygen to maintain the tension of that gas at its normal value." (2)

In another laboratory experiment Bert placed a sparrow in the compression chamber made of pneumatic glass bells and exposed it to high pressures (compression). He then decompressed the bird rapidly to atmospheric pressure, at which time the bird suddenly died. Upon inspection of the body he found air bubbles in the arteries and heart. The same effect resulted during similar experiments performed with rats and small dogs. (5, page 115)

Robert Boyl had observed bubbles in the eyes of a snake he placed in a compression tank he invented, although no further investigations were made at that time into the nature or cause of the bubbles. Bert, however, benefited from improved laboratory equipment. (5, page 116)

Bert concluded that higher atmospheric pressures (as what would occur as one travels deeper under water) result in increased oxygen tensions in the air and blood. The remedy here would be avoidance of too high a pressure (such as greater than 5-6 atmospheres), and gradual decompression back to atmospheric pressure (1 atmosphere). (2)

He observed that the effects of high pressures may kill not only humans and animals, but plants too.  (2)

While the significance of this work may not have been immediately known, the value of it was immediately recognized by the scientific community.  For this work the Academy of Sciences awarded him a prize of twenty thousand francs. (2)

His experiments would have an impact in many areas of science and medicine.

His conclusions about the effects of diminished pressure resulted in equipment, such as oxygen tanks and masks, that made aviation possible.  For this reason, he is often referred to as the father of aviation medicine.

Improved methods of storing and delivering oxygen was also thought to benefit people with respiratory disorders, and so research was eventually done in this regard, some of it by Bert himself.

His conclusions about the effects of increased pressure resulted in better knowledge of decompression sickness or bends. It occurs when a person moves from deep water (where the pressure is higher) to the surface (where the pressure is lower) too fast. This causes bubbles to escape into the blood and tissues, and can cause symptoms such as headache, joint pain, nose bleeding, vertigo, shortness of breath, nausea, vomiting, and sometimes death.

This is a small compression chamber made of a pneumatic glass jar.
Bert was able to use it to expose a sparrow to low pressures.
He reduced the pressure using a manometric tube,
observing at what point the bird started to suffer.
He used the India rubber bag to administer oxygen to the bird,
and "at once the bird becomes himself again," he wrote.
He concluded that at high altitudes, where the pressure was low,
: "it appears it is not the lowering of mechanical pressure
that produces the symptoms, but the low tension of oxygen
of the dilated air, which low tension prevents the oxygen from
entering the blood in sufficient quantity." (7)

So Bert became interested in helping people with breathing difficulties during the early 1870s. He said it was already known (such as by the works of Tavarie) that compressed air (higher pressure) helped people with anemia, chronic bronchitis, and emphysematous asthma. The result was easier breathing, and a lower heart rate. (7)(8 page VII)

Improved knowledge of the effects of high pressure on the human body resulted in Bert, and various other physicians, trying to invent machines that would adjust the pressure of inspired air to relieve the feeling of air hunger. Such machines would be experimented on patients of various lung disorders, including asthma.

In fact, in his 1877 article "Atmospheric pressure and life," Bert said:

The great influence that may be exerted upon living beings by atmospheric pressure is now questioned by none, and there is even a disposition to exaggerate its importance. If the barometric column rises or falls a few millimetres, nervous people affected with the asthma perceive phenomena, whether of a beneficial or of a noxious kind, which they do not hesitate to attribute to the weight or to the lightness of the atmosphere. But if this were the only cause of their sensations, then they should experience the same symptoms whenever they subject themselves to equal variations of pressure, as in passing from the level of the sea to a point only a few feet above it, or vice versa. (7)

In his 1878 book "Barometric Pressure," he published the results of his experiments on barometric pressure. He dedicated the book to his friend, and the man who funded the project, Dr. Jourdanet.

This is a compression chamber that allowed Bert to measure
the effects of barometric pressure on himself and others.
Inside was an Indian rubber bag so he could inhale oxygen.
Access points allowed him to take blood samples
to determine changes in blood oxygen tensions.
He exposed himself to decreased pressures.  Once he
started to feel symptoms he inhaled oxygen.  He wrote:
"But all these symptoms disappeared as by enchantment
so soon as I respired some of the oxygen in the bag;
returning, however, when I again breathed the air in
the cylinder."  (7) 

There would be many devices invented, and many failed experiments, over the next hundred years, before a truly effective, and mass producible, device would be invented to truly help patient's with respiratory disorders. Yet it was Bert's work that

He also performed work using anesthetics such as chloroform, and to administer it he devised an apparatus that allowed the patient to inhale an ideal percentage of the compound. (2)(3, page 427)

Along with being a successful physician and scientist, he was also a successful politician.

As he was performing his experiments on pressure,
he started to wonder how the world was created.
In regards to animals dying due to compression, he wrote:
"Thus it is the oxygen that is to blame.  Oxygen at too high
a tension destroys animal life.  Long I hesitated to characterize
as a poison the 'nursing father' of everything that lives, but there
was no help for it.  Oxygen, which gives us life, slays also,
when administered in too strong a dose.  I have had to study
thoroughly this paradoxal poison to determine the different
effects of varying doses, and its action upon our tissues. (7)

So after Williams, Longet and Bert all performed experiments to prove the spasmotic theory of asthma, you probably thought the subject was settled. Well, not quite. There still remained skeptics with credible arguments against it.

J.B. Berkart, in his 1878 book "On Asthma," explained that, during his work on asthma, Bert had a difficult time getting the air passages to contract until he realized that he had been over inflating the lungs.

Berkart said it was only when he provided less inflation that he was finally able to induce the air passages to...

"...contract... upon electrical irritation, applied either directly to it or to the pneumogastric nerve. But the contractions were so feeble and slow as to induce Bert to think that they had no active share in the mechanism of respiration. Moreover, the paralysis of the bronchial muscles, following the section of the vagus, did not appear to influence in that least the function of nutrition of the lungs. Thus the integrity of those muscles, not being indispensable to an efficient ventilation of the lungs, it seemed not unreasonable to conclude that their spasmodic contractions could hardly have the effect generally assigned to them." (4, page 42-43)(9,page 5)

Berkart said that Bert's experiments did not initially demonstrate contraction of the lungs because he over inflated them.

Berkart believed that Bert's experiments demonstrated proof that the air passages may constrict as Williams proved, but this did not occur in asthma because most asthmatics also present with emphysema, which is essentially over inflation of the lungs. (4, page 103)

Berkart's theory was respected among the medical community, although it did not have a long lasting influence.

In 1886 he was appointed governor-general of Tonquin, and soon thereafter his health started to fail. On a return to France during the year he gave a farewell speech at a meeting of the Academy of sciences, supposedly because he knew he was ill. He died of dysentry on November, 11, 1886. (2)

References:

1. Geddings, W.H., author of the chapter on "Bronchial Asthma," in the book  "A System of Practical Medicine," edited by William Pepper and Louis Star,Volume 3, 1885, Philadelphia, Lea Brothers and Co.
2. "Sketch of Paul Bert," Popular Science Monthly," July, 1888, Volume 33, compliments of wikisource.org, http://en.wikisource.org/wiki/Popular_Science_Monthly/Volume_33/July_1888/Sketch_of_Paul_Bert, accessed 2/6/14
3. Waller, A., "Meeting of the society of Anaesthetists: Dosage in Anaesthetics," The Clinical Journal, April 6, 1898, pages 426-430, volume XI, October 27- April 20, 1898, Sixth Year, Edited by L. Eliot Creasy, 1898, London, The Medical Publishing Company
4. Berkart, J.B., "On Asthma: It's pathology and treatment," 1878, London, J. & A. Churchill
5. Phillips, John L., "The Bends," 1998, Yale University
6. Tissier,Paul Lewis Alexandre, edited by Solomon Solis Cohen, "Pneumotherapy: Including Aerotherapy and inhalation methods," volume X, 1903, Philadelphia, P. Blakiston's Sons and Co., pages 296-224.  If the profession of respiratory therapy existed in their era, we would be reading their books.  However, as it was, their books were written for the medical profession. All of the material from this post is from Tissier's book unless otherwise noted in the above paragraphs. Tissier page 72
7. Bert, Paul,  "Atmospheric pressure and life," Translated from the French by J. Fitzgerald, Popular Science Monthy, July, 1877, volume 11, http://en.wikisource.org/wiki/Popular_Science_Monthly/Volume_11/July_1877/Atmospheric_Pressure_and_Life, accessed 2/8/14
8. Fulton, John F., author of the Forward to Paul Bert's book "Barometric Pressure," 1843, Columbus, Ohio, The F. J. Heer Printing Company
9. Bert, Paul,  "Barometric Pressure," 1843, Columbus, Ohio, The F. J. Heer Printing Company
10. Dobell, Horace, "On Asthma: It's nature and treatment," 1886, London, Smith, Elder and Co
11. Brown, Orville Harry, "Asthma, presenting an exposition of nonpassive expiration theory," 1917, St. Louis, C.V. Mosby Company
12. Thorowgood, John Charles, "Notes on Asthma," 1878, 3rd edition, London, J and A Churchill
13. Thowowgood, John Charles, "The Lettsomian Lectures: delivered at the Medical Society of London, 1879, on bronchial asthma: it's causes, pathology and treatment," 1879, London, Bailliere, Tindall, and Cox
14. West, Samuel Hatch, "Diseases of the organs of respiration," volume II, 1902, London, Charles Griffin & Company, Limited 

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1860: Salter proved nervous theory of asthma

Dr. Salter believed asthma was a nervous disease. He believed the evidence asthma was nervous was so abounding that it could not be denied.

While the idea asthma was nervous was postulated back in the ancient era, and even postulated by physicians such as Jan Baptiste van Helmont and Thomas Willis in the 17th century, and William Cullen in the 18th century, it really didn't engulf the medical community until it was re-introduced by Salter's mentor, Dr. Robert Bentley Todd. 

While Dr. Salter didn't accept all Dr. Todd's ideas about asthma, he did accept his notion that asthma was nervous.  By writing his famous articles on asthma that were ultimately published in the 1960 book "On Asthma: Its Pathology and Treatment," Salter brought the idea to the mainstream of physicians, many of whom accepted it as fact, even treating it as a nervous disorder.  Even 20th cen

Even the famous 20th century asthma expert Frances M. Rackemann was a supporter of Salter's nervous theory of asthma.  Even while disproved during the 1950s once the immune system was learned of, his ideas continued to be accepted, even into the 1970s and 1980s.

He even went as far as to offer to the  medical community evidence that asthma was nervous.

• Fatigue and mental emotion bring about an attack
• Remedies that appeal to the nervous system allay an attack, such as stramonium, antimony and chloriform. 
• The periodicity of asthma. It goes away and comes back without warning by recurrence of hay fever, indigestion after dinner, expectoration after a good nights sleep, etc. 
• Symptoms of asthma, such as clear urine (nervous urine), nervous headache, drowsiness, and an attack after laughter or animation. These are similar to hysteria and epilepsy.
• No organic change in the lungs during or following an attack. Post mortem exam of asthmatics shows no organic changes, or damage, to the lungs. They are essentially normal.
• Asthma is muscular in that it is caused by muscular fibre that spasm and squeeze the air passages of the lungs. Muscular disorders like this are always nervous as the nerves are connected with the mind (4 page 13-16)

Salter didn't deny asthma was a spasmodic disease of the lungs, yet he believed this was the result of a nervous condition of the patient.   He said:

The inflammation or congestion of the mucous surface appears to be the stimulus that, through the nerves of the air tubes, excites the muscular wall to contract. (6, page 92)

It was also for this reason he recommended remedies that would soothe the mind of the patient, such as alcohol, cigarettes, morphine, formaldehyde, strammonium, antimony, antispasmotics, and direct nervous depressants. (6, page 33)

His favorite remedy was chloroform because "just a few whiffs, and the asthma is gone; a dyspnea that a few seconds before seemed to threaten life is replaced by a breathing calm and tranquil." (4, page 33)

Thus, he wrote, remembering that the action of these remedies on the nervous system, "it is impossible to help seeing in this the most conclusive proof that the symptoms are due to a nervous cause."  (4, page 33 & 34)

He described one symptoms of asthma as itching of the skin under the chin.  I personally have experienced this when my asthma has been bad, and I think to this day there is yet no scientific explanation for it.  Yet Dr. Salter was convinced the cause was an "irritation at the roots of these nerves.  (5)

So he believed nervous asthma resulted in spasmotic asthma.  Actually, he believed nervous asthma was spasmotic asthma, and in this way he was a supporter of both the nervous and spasmotic theories of asthma.

He defined nervous, or spasmotic, asthma as "paroxysmal dyspnea of a peculiar character, generally periodic, with intervals of healthy respiration between the atatcks."

He said asthma was more common than believed, yet pure asthma, or "asthma without the slightest organic complications," was rare. (4)

However, if the nervous disposition lead to asthma attacks that were frequent, this may result in "permanent injury on the lungs, and even the heart."

He said:

"Asthma is not the less asthma because it has produced certain organic changes which complicate it; and many cases are primarily and essentially asthma that ultimately become, and are called, emphysema and heart disease." (4, page 17)

He was also a realist, and did not claim to offer a cure for the disease.  He believed that since the disease was nervous in origin, there really was not truly effective treatment.  He said:

"...the treatment is regarded as palliative. It must be admitted that the remedies for asthma are of very irregular and uncertain operation: that probably there is no single remedy that is not inoperative in a large number of cases; that that which is useful in one is valueless in another; while there are many cases that resist all remedies. If this intractability of asthma were doubtfull, the large number of remedies that have been suggested would be a sufficient proof of it."

 Further reading:

• 1823-1871:  Dr. Salter offers proof asthma is nervous
• 1850s: Dr. Salter's Asthma Features (2/14/14)
• 1850s: Dr. Salter's Varieties of Asthma (2/20/14)
• 1850s  Dr. Salter's asthma triggers (2/27/14)
• 1850s: Dr. Salter's asthma signs and symptoms (3/6/14)
• 1850s: Dr. Salter's Consequences of asthma (3/13/14)
• 1850s: Dr. Salter's Asthma Remedies (3/27/14)
• 1850s: Dr. Salter's prognosis for asthmatics (4/10/14)

Click here for more asthma history.

References:

1. "The Late Henry Hyde Salter," Medical Times and Gazette, Sept. 13, 1871. 
2. McCulough, David, "Mornings on Horseback," 1981, New York
3. Sakula, Alex, "Henry Hyde Salter (1823-71) a biographical sketch," Thorax, 1985; 40; pages 887-888.
4. Salter, Henry Hyde, "On Asthma:  Its Pathology and Treatment," 1861, London, Philadelphia
5. Kidd, G.H. Dr., "On the pathology of Asthma," Dublin Quarterly Journal of Med. Science," 1861, May,
6. Salter, Henry Hyde, "Asthma: It's Pathology and Treatment," 1864, Philadelphia, Blanchard and Lea

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