“For breath too is nutriment”

The American VOL.

XIX

Journal

SEPTEMBER,

of Medicine 1955

Editorial “For Breath Too Is Nutriment”

W

There is some justice in our view. The mire of chronic non-specific pulmonary disease is not new, and the weirdly festooned and clustered woods of pulmonary impairment have always been; but as gloom dispels in the growing light of medical science we can see the situation more vividly if not more clearly. Meanwhile the proportion between middle and older aged in the population is continually increasing, the killing diseases of childhood and youth are decreasing, so that the relative incidence and importance of the insidiously progressive chronic non-specific pulmonary diseases are multiplying. Some confusions concerning the origin of dyspnea have been resolved. In many instances the heart may be exonerated and the lungs indicted. If we erroneously diagnose failure of the former when the latter is the culprit, time will confirm us in our error because heart failure will inevitably occur as a result of pulmonary failure, if something else does not carry our patient off in the meantime. Finally, effective diagnostic and therapeutic measures have come much more plentifully to our hands. That a situation is susceptible of management imposes upon us a duty to recognize and to treat it skillfully. Much of our self-recognized befuddlement is derived from the fact that at the time we attended medical school chronic pulmonary insufficiency was a troublesome, refractory and fortunately (in a sense) an infrequently recognized condition receiving minimal curricular attention. We feel the lack of systematic grounding in the basic principles and now, harried, we are attempting to fill the hiatus piecemeal. Perhaps it would be comforting to look to the past to see how long a path has really been

we treat a patient with chronic “non-specific” pulmonary disease we often feel ourselves in a trackless quagmire of contradictory recommendations for therapy in a condition which we are ill equipped to diagnose and which, by its bewildering complexity of seemingly unconnected manifestations, paralyzes our powers. All around us, among our professional colleagues, in the current medical literature, in hospital charts and laboratory reports there is an incomprehensible chatter, a flowing alphabet soup of cryptic and code-like jargon, foreign to our ear, of M. B. C. and F. R. C. interspersed all too frequently with an algebraic expression or, worst of all, with that Indian sign to the medical mind, a differential or an integral symbol. A congeries of factors seems to have thrust us into this slough: here are bronchodilators, there are emphysema belts, yonder aerosol generators (perhaps with design to insufflate or exsufflate), everywhere are antibiotics in bewildering profusion which might cure our patient’s infection or, who knows, might turn the bronchial passages into a defenseless playground for an overgrowth of ordinarily innocuous but now slimily coalescent pathogens raised like an army of zombies from the normal microbial flora. And down the hall dwells a young scientist with burning eyes and glistening spirometers who, facile in crypto-alphabetese, would, at the twist of a stopcock, turn emphysema into fibrosis while threading a heart with nylon tubes. Not the least of our reactions is guilt. We feel we should know, that others do know, the solid from the quicksand in this swamp, and boundless anxiety issues from our neurotic guilt. HEN

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traversed and how slowly we have moved along it. A place to start might be that “ . . . earliest surviving example of observation and conclusion, the oldest known evidence of an inductive process in the history of the human mind,” the Edwin Smith surgical papyrus (Breasted). This document, which dates from the sixteenth century B.C., copies a much older text. The latter, about the twenty-sixth century B.C., was in itself an annotated version of one originating, it is thought, in the Pyramid Age around the thirtieth century B.C. The instructive form directs us to examine the patient and conclude one of the following: “an ailment which I will treat”; “an ailment with which I will contend” or “an ailment not to be treated.” Chronic pulmonary disease of the sort which concerns us never falls in the first category of curable illness and should not be placed in the third of hopeless illness. Chronic disabling pulmonary disease is an ailment with which the physician must “contend.” To do this we must know the natural history of the disorders we propose to manage “I hold it is an excellent thing for a physician to practice said Hippocrates (Prognostica) “for forecasting,” if he discover and declare unaided by the side of his patients the present, the past and the future and fill in the gaps in the account given by the sick, he will be the more believed to understand the cases, so that men will confidently entrust themselves to him for treatment. Furthermore, he will carry out the treatment best if he know beforehand from the present symptoms what will take place later. . . . ” Hippocrates, if he were about, would nowadays be willing to modify “unaided” to encourage recourse to the needed specialists in radiology, electrocardiography pulmonary function, bacteriology and cardiac catheterization, but would doubtless sternly insist that we remain at the patient’s side to convert the specialists’ information to useful plans for the patient. This we can do only through a working comprehension of these ramifications of the modern art acquired from study, if not from practice, of their technics. Anaximenes of Miletos proposed air, pneuma, as the primary substance “ . . . permeating and indeed, from the biologic everything” point of view, such is true. Every part and system of the body is permeated with air and dependent upon an endlessly refreshed supply of it for wellbeing. Interference with the bodily aerating

equipment must of necessity manifest itself in myriad ways. Complexity, however, cannot cause mental panic unless we allow it. A child of seven steps up to a television set and unhesitatingly tunes in a station, adjusts the horizontal and vertical raster control circuits to the locking signals of the transmitting station, focuses the electronic beam unerringly, adjusts the bias of the control grid of the cathode ray tube to a degree of apparent contrast to suit his fancy, turns the audio volume control wide open and thunders off into outer space in a reaction-engined craft without a qualm. Confronted with a circuit diagram of the set, he would blink with incomprehension, a reaction that will persist with him well into engineering school a decade and more later. There he will be taught an engineer’s trick: reduce the incomprehensible whole into comprehensible parts. Here is the power supply, here its filter network, here the automatic volume control, and so on. Thus, piece by piece, the whole becomes simple. There is no scientific concept borne of the human mind which is not simple in its basic elements. To get at these basic elements may be another matter! When the work is new it is difficult to thread a way among the conflicting data, but with time and the work of many minds the findings are digested, condensed, sorted and simplified to a teachable or learnable unit of knowledge. How far we go in our studies of this subject is a purely personal matter but whatever we attempt all will be lost if we swamp ourselves in complexity instead of systematizing our attack on the problem and subdividing it into comprehensible elements. This is difficult if not impossible to do alone in a field where areas of comprehension are chequered among larger areas of ignorance. Engineers can teach us another trick for working with systems we do not or cannot fully understand: the useful tool of the four terminal network parameters. Here an electronic device is envisaged as though two wires, the input circuit, disappeared through two terminals into a “little black box,” and two wires, the output circuit, emerge through two other terminals from the opposite side. It is often entirely unnecessary to know the contents of the box; it may be enough to know what changes are produced in the output circuit by certain changes in input, and vice versa. A “little black box” can be made to contain that part of any system about which the technical details AMERICAN

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Edi tori al are unknown, or as much or as little as desired. So if for a given amount of power fed into the “little black box” a lesser amount emerges, it is evident the loss occurred within the box, while if there is gain of power it is axiomatic that the box is playing an active role and its behavior in this respect could be characterized by a generator of appropriate properties. In either event we would want to know where the lost electricity went or where the gained energy originated, but these are questions for the research laboratory. The “little black box” will serve very well for the bedside. It has to be accepted definitely that we cannot understand everything. As researchers open one by one the “little black boxes” and show their contents to us, more and more unopened boxes are revealed. It is poor research indeed which does not raise more ghosts than it lays. We may conveniently place such matters which we do not understand into useful “little black boxes.” Thus we can make intelligent use of the knowledge that the volume of air moved by the bellows action of the lung during maximal voluntary hyperventilation increased 20 per cent following administration to the patient of a bronchodilator drug to lead us to the conclusion that bronchoconstriction is a factor in our patient’s malady despite a limited comprehension of all the complex mechanisms involved. Such reasoning should not be adduced as an excuse for unnecessary ignorance but rather as a working technic with what knowledge has been allowed us. Empedocles of Agrigentum, he of the four elements, fire, air, water and earth, who flourished early in the fifth century B.C., performed a crucial experiment which proved the corporeality of air. By plugging the hole in one end of a clepsydra (a hollow vessel with holes at each end) with his finger and immersing the vessel in water he showed that the entrapped air prevented the entrance of water until he removed his finger from the top hole and let the air escape. Not much of vital interest to physiologists was added to this information about air until 1668 A.o., some twenty-one centuries later. The Hippocratic physicians were close observers of the respiratory movements. Thus the second case described in Ekidemics I: “from the beginning the breath in this case was throughout we may suppose, rare and large.” Hyperpnea, since the clinical picture described is dehydration and metabolic acidosis in a patient dying of acute fever with copious diarrhea. Again, SEPTEMBER,

1955

Cheyne (1818) and Stokes (1846) were antedated in their observations of the kind of breathing which commonly bears their names by the author of Case 15 in Epidemics III:“Respirations rare and large with long intervals becoming afterwards short.” The forty-eighth chapter of De Alimento, an aphoristic work of the Hippocratic corpus of uncertain authorship written about the turn of the fifth century B.C., which is taken as the text for this editorial, shows the preoccupation of this school with the way of breathing and the “obscure sybylline” utterances they were forced to take refuge in because of the lack of real comprehension of respiration. To recognize air as a Sarton points out, could only then “food,” have been a guess or a metaphor. The point was not proved until Priestley in 1772 rediscovered Mayow’s “igneo-aerial” spirit which he isolated as oxygen, and Lavoisier soon afterwards disposed of the phlogiston theory setting the matter straight for all time. Bewilderment about the purpose of respiration persisted for centuries despite the fact that it was known to the earliest Egyptians, even to their Paleolithic predecessors, that air was essential to life. Murder by suffocation is not a new invention, and execution by entombment (and consequent suffocation) did not begin with Aida. Jelliffe traces the more recent developments: Galen thought respiration was for the purpose of cooling the heart and this doctrine persisted until recent times. Harvey recognized the existence of “two different currents” of the blood but supposed one to generate the vital spirit in the left side of the heart, the other to get rid of the foul vapors and the heat of the innate fire burning in the heart. Von Helmont recognized the existence of “fixed air” (carbon dioxide) from his studies on fermentation but had no idea what it was, and the concept was lost. Borelli elaborated upon the concept of the bellows action of the chest and with others through the seventeenth century clarified the mechanics of respiration, coupling in the observations of Malpighi on the minute structure of the lung and advancing finally to the point of recognizing that the “particles” of air enter into and become mixed with the blood. Hooke also proved the necessity of air for life by experiments in artificial respiration, and Lower “by his careful transfusion experiments demonstrated that the difference between dark venous blood and lighter arterial blood was due to the admix-

Editorial ture of air thus explaining the color change which had been recorded for thousands of years and referred to thousands of causes.” John Mayow in 1668 cracked the problem left for him by Empedocles two thousand years before proving that air, while indeed it had corporeality, was not a single substance.* “Not all of the air was used by the lungs in influencing the blood but only a certain part of it, and although he called it by a different name (spiritus nitro-aerius) it was that part now known He saw that respiration was a as oxygen.” that process “ . . . analogous to combustion, both fire and breathing removed from air the (Foster). Stephen Hales igneoaerial particles” first stated the principle of free and combined gases and Joseph Black rediscovered Von Helmont’s “fixed air,” the carbon dioxide given off by the lung. When, after a hundred years of forgetfulness of Mayow’s work, Priestley and Lavoisier, as earlier mentioned, elaborated upon the elements of external gaseous respiration, it remained only for Gustavus Magnus, just a century ago, to prove the presence of the gases in different proportions in the blood and thus complete “the last chapter in the unraveling of this secret of nature.” The stage was set for the great advances in pulmonary physiology, espe*Some credit this discovery.

Robert

Boyle or Robert

Hooke with

cially in its quantitative aspects, made over the last century. Unfortunately the original literature on chronic pulmonary disease is enormous. In one segment of the field alone, pulmonary function testing, over seven hundred authors during the last two decades have published articles which have attracted enough attention to be quoted one or more times in other papers. The leading articles have been disseminated for the most part among forty-three different journals without much concentration in any particular one. Just in the last two decades have reviews, texts and, most useful, organized postgraduate courses on the subject begun to appear. Widespread use of Roentgen diagnosis, the advent of practical tests of pulmonary function, the ready availability of effective antibiotics and effective therapeutic products of synthetic chemistry, particularly bronchodilators, all within our clinical lifetime is bringing us nearer comprehension of that mystical but inspired passage: “Pulsations of veins and breathing of the lungs according to age, harmonious and unharmonious, signs of disease and of health, and of health more than disease, and of disease more than health. For breath too is nutriment.” GEORGE R. MENEELY, M.D. Veterans Administration Hospital Nashville, Tennessee

AMERICAN

JOURNAL

OF

MEDICINE