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                HISTORICAL PERSPECTIVE ON PULMONARY MEDICINE

                     Lawrence Martin, M.D., FACP, FCCP
          Chief, Division of Pulmonary and Critical Care Medicine
                 Mt. Sinai Medical Center, Cleveland, Ohio
                            Phone: 216-421-3708
                             FAX: 216-421-6952

      (Reprinted from The House Officer's Survival Guide: Rules, Laws,
           Lists and Other Medical Musings, Lakeside Press, 1996)

Look around your hospital. Did it always have a pulmonary function
laboratory? An intensive care unit? Facilities for cardiac catheterization?
A computerized laboratory? If it is newly built or only a few years old, the
answer is probably "yes" to all these questions. But if you work in a
hospital built before the 1950s, the answer to all is "no." Since the end of
World War II there has been a technologic revolution in patient care. In our
daily practice we use machines, prescribe drugs and perform operations
inconceivable a few decades ago.

For the most part, diseases that we treat are not new. Certain
microorganisms may be newly recognized (e.g., Legionella bacterium and human
immunodeficiency virus), and some conditions may be more common than in
years past (e.g., lung cancer and myocardial infarction), but the basic
disease processes are the same. There have always been patients suffering
from cardiac and respiratory failure, pneumonia, lung abscess, shock, sepsis
and asthma. How did physicians cope with these patients 200 years ago? A
century ago? Fifty, twenty, even ten years ago? Answers to these general
questions provide a historical perspective, which can be defined as the
viewing of our current situation in light of medical history.

There is sometimes a tendency to think that the way we care for patients is
the only way, the best way, the universal way. Not so, of course. By
examining how medical problems were managed in the past, we can better
appreciate today's medical environment and perhaps glimpse an idea of what
practice might be like years hence. Medical care has changed radically over
the generations and will surely continue to change in dramatic ways.

To illustrate how medical practice has changed, four case histories are
presented; each is from the medical literature and is representative of
"state-of-the-art" medical practice for its era.

     Case I (Laennec, 1818)
     A man, aged 29, caught a severe catarrh from exposure to much cold
     in the beginning of October, which he neglected....This catarrh,
     after a few weeks, was followed by spitting of blood for several
     days and, subsequently, by a continual cough, dyspnoea and
     emaciation. In the beginning of February he came into hospital. At
     this time he was evidently in a confirmed consumption--being
     affected with great emaciation, frequent cough, yellow opaque
     sputa, dyspnoea, diarrhea....Things continued much in the same way
     until the 17th, when the supervention of more febrile symptoms
     indicated a slight peripneumony. On applying the cylinder, it was
     found that respiration was not at all audible on the anterior and
     lateral portions of the left side of the chest; while percussion
     gave a much distincter sound than on the right side; and
     succussion of the trunk produced the characteristic noise of
     fluctuation. From these circumstances, being convinced of the
     existence of both air and pus in the cavity of the pleura, and
     seeing no other means of alleviating the patient, I proposed the
     operation of empyema. This however was not performed, as he died
     the same day.

This case is from one of the earliest "classics" of respiratory medicine,
Laennec's Treatise on the Diseases of the Chest, published in 1818. In 1816
Laennec (1781-1826) invented the stethoscope (the "cylinder" in this case
report). As reported in Treatise, "I was consulted by a young woman laboring
under general symptoms of diseased heart, and in whose case percussion and
the application of the hand were of little avail on account of the great
degree of fatness." By rolling a sheaf of paper into a cylinder and placing
one end over her heart, he found "I could thereby perceive the action of the
heart in a manner much more clear and distinct than I had ever been able to
do by the immediate application of the ear."

Laennec later replaced the rolled paper with a solid wood cylinder a foot
long and two inches in diameter, with a hollow center. "This instrument. .
.I commonly designate simply the Cylinder, sometimes the Stethoscope."

From publication of Laennec's Treatise onward, for about 100 years, the
stethoscope was the premier tool for diagnosing chest diseases pre-mortem.
Not until the introduction of chest radiology in the early 1900s was a
better tool available.

At autopsy this patient was found to have tuberculous empyema, which Laennec
diagnosed after careful dissection. Without antibiotics, it is unlikely that
even "operation of empyema" would have helped. Of course, anesthesia was
also unavailable to relieve the pain of surgery.

Laennec was a master diagnostician. He "fixed definitely the clinical
picture of the disease [tuberculosis]...having separated it by means of
auscultation and his pathological studies from all similar affections of the
lungs" (Walsh, 1907). Unfortunately, like all doctors of his era, Laennec
could not offer meaningful treatment for tuberculosis. The next case, from
half a century later, shows a different approach to tuberculosis (phthisis
pulmonalia).

     Case II (Mackey, 1869)
     Phthisis pulmonalia. Mrs. W.--age 31, who had lost her father and
     sisters of consumption, consulted me in Dec. 1867. For the last
     six months had had cough, for the last three had been emaciated,
     and at this time had the prostration, night sweats, diarrhea, and
     hectic of the third stage of phthisis; hemoptysis had occurred
     several times: the expectoration was generally purulent. There
     were violent pains, especially over left chest, and examination
     revealed a fine crepitus at apex of left lung. The patient was
     treated with ordinary medicines, and improved gradually. Opium in
     the form of an atomized spray was found to be the best medicine
     for relieving cough, and procuring sleep; tincture of steel and
     carbolic acid used in the same manner relieved, to a certain
     extent, the profuse expectoration; and although the case became
     complicated with a peri-uterine haematocele, in February 1868 she
     rallied from this also.

     It was July 1868 before she could walk as far as my house. Her
     principal symptoms then were debility, pains in the chest, cough,
     and copious muco-purulent sputum. At this point she began
     inhalations of oxygen in the proportion of 6 pints to 60 of air,
     increasing to 12 pints. She took inhalations at intervals of two
     days, and then found the above symptoms so relieved as to be able
     to omit all treatment for a time. She herself attributed great
     benefit to the gas, and was taking no other special medicine at
     the time. Since then she has borne fairly well the cares of a
     large family. She has gained flesh, and though there is still a
     frequent cough, and sputum, a mucous rale about the left apex (I
     examined the chest two days ago), the progress of the disease is
     arrested for a time at least.

Today both Laennec's and Mackey's patients would have a chest x-ray, which
would no doubt show abnormalities. Sputum examination and culture would
confirm the diagnosis, and both patients would receive anti-tuberculous
drugs. But it was only in 1882 that Robert Koch discovered the tuberculous
bacillus, in 1895 that Roentgen discovered x-rays, and in the 1940s that the
first successful anti-TB drug (streptomycin) became available.

As for oxygen therapy, there is no reason to suppose that the intermittent
inhalations this patient received were of any benefit. Oxygen, discovered in
1774 by Joseph Priestley, was employed for medical purposes shortly
afterward. Nevertheless, it was not until well into the twentieth century
that oxygen therapy was placed on a rational, scientific basis.

For almost the entire nineteenth century, oxygen was prescribed only for
intermittent use. The first case report of continuous oxygen therapy was
published in 1890 (Blodgett). If Dr. Mackey's patient was indeed hypoxic,
oxygen delivered intermittently certainly did not help since the body does
not store oxygen. Moreover, tuberculous organisms seem to favor lung regions
with a high alveolar partial pressure of oxygen. After this fact became
known and before the advent of anti-tuberculous therapy, temporary
pneumothorax was in vogue as a treatment for tuberculosis. An even more
radical procedure was thoracoplasty, which entailed removal of part of the
rib cage to permanently collapse the infected lung. The idea behind both
procedures was to make the involved lung airless and so starve the
tuberculous organisms from lack of oxygen. Although these techniques often
did help, they also caused considerable morbidity; compared to modern day
chemo-therapy, lung collapse is primitive treatment.

     Case III (Barach, 1927)
     A man, aged 50, was sick with fever, cough and prostration of two
     weeks' duration. He was known to have had bronchiectasis for one
     year. On admission he was deeply cyanotic, dyspneic, and toxic.
     The lung signs gave evidence of bronchiectatic cavities and a
     diffuse bronchopneumonia. He was put in an oxygen tent with a
     concentration of 40 per cent of oxygen. At the end of seven days
     he was free from cyanosis, moderately dyspneic, very toxic and
     stuporous. The tent was removed. Four hours later, he was deeply
     cyanotic, the hands and face were both blue, he has gasping for
     breath, he was very restless and he was trying to get out of bed.
     His pulse had risen from 116 to 152 and the respiratory rate from
     36 to 50. From a condition of comparative comfort he had passed
     into one of acute distress, restlessness and imminent collapse. He
     was transferred to the oxygen chamber, and in three hours after 40
     per cent of oxygen had been established, his condition returned to
     that point before the removal of the tent.

The modern era of oxygen therapy is often said to have begun with the work
of John Scott Haldane, the great English physiologist. Haldane used oxygen
therapy for victims of war gas injuries and published a brief paper in 1917
outlining the rationale for use of the gas (Haldane). Case III is from a
paper on methods of oxygen treatment by Dr. Alan Barach, another pioneer in
the field of oxygen therapy. During the 1920s, Dr. Barach led in the
development of oxygen tents for use in treating hypoxemic patients. Note
that by this time oxygen was used on a continuous basis, a much more
physiologic approach than the nineteenth century's intermittent technique.

Of interest is that no blood gas values were reported in Dr. Barach's case;
even in the best hospitals of the era, blood gas measurements were not
routinely available. lt would take another 35 years for this test to enter
the mainstream of clinical medicine. Today blood gas measurements are
routine in cases of severe hypoxemia, and in are themselves being slowly
edged out by newer, non-invasive methods of measurement, particularly pulse
oximetry.

The first arterial puncture performed on humans was done in 1912, by Hurter,
a German physician. In 1919 arterial blood gas analysis was first used as a
diagnostic procedure. Employing Hurter's radial artery puncture technique,
W.C. Stadie (1919) measured oxygen saturation in patients with pneumonia.
Stadie was able to show that cyanosis seen in his critically ill patients
resulted from incomplete oxygenation of hemoglobin.

Measurement of PO2 and partial pressure of carbon dioxide (PCO2) proved to
be more difficult than measurement of the oxygen saturation. lt was not
until the introduction of Clark's platinum electrode in 1953 that direct PO2
measurement became routinely feasible (Clark, 1953). Later a PCO2 electrode
was developed, and by the 1960s blood gas electrodes were commercially
available.

Finally, it is of interest that Barach's patient did not receive artificial
ventilation - it was also not available in 1927. Even though the oxygen tent
relieved the patient's cyanosis, he remained "moderately dyspneic, very
toxic and stuperous." The outcome is not reported.

     Case IV (Louria, 1959)
     A.Z. A 21 year old woman was admitted on Nov. 8, 1957, because of
     profound respiratory distress. Three days prior to admission she
     had developed a sore throat, myalgia, bifrontal headache, a dry
     cough and fever to 103F (oral). She was seen by a physician who
     noted no respiratory distress or abnormalities on physical
     examination of the chest. The night prior to admission she
     developed pleuritic right chest pain, tachypnea and dyspnea. On
     the morning of admission her respiratory distress became
     increasingly severe. When seen by her physician she was markedly
     cyanotic and audible bubbling sounds could be heard at
     considerable distance from the patient.

     Physical examination on admission revealed a critically ill,
     anxious dyspneic woman who was intensely cyanotic. Her temperature
     was 40.3 C, respiratory rate 60 per minute, pulse 160 per minute,
     and blood pressure 130/70 mm Hg...Crackling inspiratory rales and
     harsh breath sounds were noted throughout both lung fields.
     Expiration was labored and appeared to be obstructed. There was
     evidence of consolidation of both lower lobes...Initial laboratory
     studies showed the white blood cell count to be 2,000 cells per
     cu. mm. with 58 per cent lymphocytes, 8 per cent monocytes, 7 per
     cent polymorphonuclear cells, 9 per cent band forms, 13 per cent
     metamyelocytes, and 5 per cent myelocytes...The patient's arterial
     oxy-hemoglobin saturation was reduced to 71.1 per cent. Sputum was
     grossly bloody and contained large numbers of gram- positive
     cocci. Hemolytic Staphylococcus aureus was grown in pure culture
     from the sputum. This organism was sensitive to erythromycin,
     chloromycetin, streptomycin and novobiocin, but resistant to
     penicillin and the tetracyclines. The Asian strain of influenza A
     virus was recovered from throat washings. The admission chest
     roentgenogram revealed dense bilateral lower lobe infiltrates with
     scattered nodular densities present in the central areas of both
     lung fields.

     The patient was given oxygen through a positive pressure oxygen
     mask, and administration of erythromycin, dihydrostreptomycin and
     chloromycetin, 2 Gm. each day, were started. Hydrocortisone, 100
     mg. every 12 hours, was injected intravenously, and prednisone,
     100 mg. daily, was given by mouth.

     Over the first four days in the hospital the patient showed
     moderate improvement. Oxyhemoglobin saturation rose to 93.9 per
     cent with use of the IPPB mask...Nevertheless, signs of
     consolidation persisted, and she remained cyanotic and tachypneic
     when oxygen therapy was discontinued.

     On the fifth hospital day the patient developed high tracheal
     obstruction which required tracheotomy and vigorous sectioning.
     Following this episode her condition worsened rapidly...A marked
     respiratory acidosis de- veloped with the arterial PCO2 rising to
     78 mm Hg. The administration of acetazolamide, 1.0 Gm. daily, was
     associated with the return of arterial blood PCO2 and pH to
     normal, but there was no improvement in the patient's clinical
     course. The onset of bloody diarrhea was associated with the
     recovery of hemolytic Staphylococcus aureus from stool cultures.
     On the sixth hospital day blood pressure fell to shock levels and
     the patient died.

Case IV is from a paper on the influenza pandemic of 1957-1958; by that time
procedures for measuring blood gases were available in some hospitals.
However, it is noteworthy that no mention of artificial ventilation is made
in this case report. Today both Cases III and IV would undoubtedly receive
artificial ventilation during their hospital courses.

When did artificial ventilation come about? According to Comroe (1977),
artificial ventilation was used in laboratory animals for centuries, with
one report dating to 1667. By the 19th century, artificial ventilation was
commonly employed in laboratory experiments. Despite the laboratory
experience, artificial ventilation was not used when clearly indicated, such
as in patients undergoing thoracic surgery in whom pneumo-thorax is always a
major problem (pneumothorax is preventable with positive pressure
insufflation of the lungs).

One factor holding back use of the technique of artificial ventilation was
the use of negative pressure rooms for thoracic surgery. In 1904, the
influential German surgeon Ernest Ferdinand Sauerbruch published his method
of operating on a patient whose body, except for the head, was enclosed in a
room kept at slightly negative air pressure; the surgeon and his assistants
were also in the negative pressure room (Comroe, 1977). With this technique,
the nonoperated lung stayed inflated throughout surgery, but the patient
still breathed on his own (albeit under anesthesia), so there was no real
artificial ventilation.

Because Sauerbruch's technique was inherently cumbersome, positive
insufflation through an endotracheal tube gradually took over. This
transition was aided by development of new technology, such as closed
circuit anesthesia apparatus (Jackson, 1927) .

Artificial ventilation outside of the operating room took a longer time to
develop. Before World War II, artificial ventilators were usually negative
pressure machines, best exemplified by the iron lung (Drinker and Shaw,
1929; Drinker and McKhann, 1929). An iron lung surrounds the patient's body
except for the head, and alternates a negative atmospheric pressure with the
ambient one, resulting in rhythmic expansion of the chest cage (and thus
inhalation) in response to the negative extra thoracic pressure. During
periods of ambient extrathoracic pressure, the lungs deflate. This type of
machine is rarely used today.

A cuirass negative pressure respirator is designed to surround only a
portion of the body, either the chest alone or the chest and abdomen
together. For a while cuirass respirators were in vogue as an alternative to
iron lungs (Collier and Affeldt, 1954). Today cuirass respirators are used
occasionally for patients with neuromuscular problems who need artificial
ventilation at home. Unfortunately, the cuirass respirator is often
difficult to fit precisely to the patient. Also, it is not helpful in
patients with significant lung or airway disease, a population for whom
positive pressure ventilation is much more beneficial.

Positive pressure artificial ventilation was gradually phased in after World
War II, receiving great impetus during the 1953 Scandinavian polio epidemic
when there were not enough iron lungs to go around; more than any other
single event, this epidemic of paralytic polio demonstrated that positive
pressure was easy to implement and every bit as effective, if not more so,
than negative pressure ventilation. Even so, positive pressure ventilators
were mostly confined to the operating room during the 1950s. With the
development throughout the 1960s of intensive care units, mechanical
positive pressure ventilation became a widely accepted technique. Today it
is a standard therapy for severe respiratory failure in all hospitals.

                                   * * *

A paradox of modern medicine is that we know so much more than in years past
and yet we practice in a way that often seems primitive against the forces
of nature. Metastatic cancer, shock, brain hemorrhage, pneumonia in the
immunocompromised patient  these and other conditions often pursue an
inexorable downhill course no matter what we do. Yet consider medical
practice without anesthetics, x-rays, or antibiotics  a primitive state, no
doubt. But these three advances only came to us in 1846, 1895, and the
1940s, respectively. What of medicine before then?

More to the point, what will our current practice look like 50, 100, or 150
years from now? Equally as backward as nineteenth century practice appears
to us? Probably so. Barring some global catastrophe, there is no reason to
doubt that our present state is anything but a transient phase in the
continuing progress of medicine.

                                 REFERENCES

Barach, AL. Acute disturbance of lung function in pneumonia: methods of
oxygen treatment. JAMA 89:1865,1927.

Blodgett, AN. The continuous inhalation of oxygen in cases of pneumonia
otherwise fatal and in other disease. Boston Med Surg J 21:481,1890.

Clark, C, Wolf, R, Granger, D, et al. Continuous recording of blood oxygen
tensions by polarography. J Appl Physiol 6:189,1953.

Collier R and Affeldt JE. Ventilatory efficiency of the cuirass respirator
in totally paralyzed chronic poliomyelitis patients. J Appl Physiol
6:531,1954.

Comroe, JH, Jr. Retrospectroscope. Menlo Park, CA, 1977, Von Gehr Press.

Drinker, PA and McKhann, CF. The iron lung First practical means of
respiratory support. JAMA 225:1476,1986.

Drinker, P, and McKhann, CF. The use of a new apparatus for the prolonged
administration of artificial respiration. I. A fatal case of poliomyelitis.
JAMA 92:1658,1929.

Drinker, P, and Shaw, LA. An apparatus for the prolonged administration of
artificial respiration. J Clin Invest 7:229, 1929.

Haldane, JS. The therapeutic administration of oxygen. Brit Med Jour
1:181,1917.

Jackson, DE. A universal artificial respiration and closed anesthesia
machine. J Lab Clin Med 12:998,1927.

Laennec, RTH. A treatise on the diseases of the chest, in which they are
described according to their anatomical characters, and their diagnosis
established on a new principle by means of acoustick instruments. T. & G.
Underwood, London, 1821. (Translated into English by John Forbes; Treatise
was originally published in France, in 1818.)

Louria, DB, Blumenfeld, HL, Ellis, JT, et al. Studies on influenza in the
pandemic of 1957-58. II. Pulmonary complications of influenza, J Clin Invest
38:213, 1959.

Mackey, E. On the therapeutical value of the inhalation of oxygen gas.
Practitioner 2:276,1869.

Stadie, WC. The oxygen of the arterial and venous blood in pneumonia and its
relation to cyanosis. I. Exp Med 30:215, 1919.

Walsh, JJ. Makers of modern medicine, New York, 1907, Fordham University
Press.

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The material at this site is intended for educational purposes and should
not be construed as medical advice or instruction.
Lawrence Martin, M.D.


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