visit pulmonary medicine page 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 103øF (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 40.3ø 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 Ä 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 Ä 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. ---------------------------------------------------------------------------- email@example.com The material at this site is intended for educational purposes and should not be construed as medical advice or instruction. Lawrence Martin, M.D.