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Some stepping stones in the history of chest medicine
hit.
SOME
J. Dis.
STEPPING STONES IN THE OF CHEST MEDICINE*
Chest
(1972)
66, 207
HISTORY
J- SMART The
London
Chest
Hospital
and
Brompton
Hospital,
London
history of medicine falls naturally into three main periods: ancient times until Galen and his work in the second century A.D. ; then, after the seven or eight hundred years of the Dark Ages, the period of awakening of understanding of anatomy and physiology from the thirteenth to the seventeenth century; and finally the period of scientific medicine when the chemistry of air and the physiological principles of respiration became established.
THE
Ancient
Times
The vital importance of breathing was obvious to the ancients and they endowed ‘breath’ with supernatural and magical powers. There was an understanding of its destination, however. In one of the Egyptian medical papyri it was recorded that ‘the breath and the spirit enter the nose and go to the heart and lungs which then distributes it to the whole body’. We owe to Hippocrates (460-315 B.C.) the insistence on high medical standards and the introduction of the systematic inductive procedure for unravelling the complexities of disease. He believed in the doctrine of the four humours-blood, phlegm, yellow bile and black bile-controlling human constitution according to the proportions in which they were present; he described pneumonia and knew something of auscultation of the chest, describing succusion sounds and friction rub. Philosophers such as Aristotle and Diogenes thought that arteries normally contained air. One of the earlier records of the anatomy of the lungs and great vessels comes from the Alexandrian school around 300 B.C. where human dissection was practised: Hprophilus is said to have introduced the terms vena arterialis to describe the vessel leading from the right side of the heart to the lungs (pulmonary artery) and arteria venalis to describe the pulmonary vein. Claudius Galen (A.D. 130~zoo), of Pergamum in Asia Minor, dominated medical teaching for nearly fourteen centuries. He postulated two types of blood -one produced by the heart and the other by the liver. The blood from the liver had to be ‘vitalized’ and this was achieved by its diffusing through the septum of the heart thereby becoming purified. The ‘fuliginous vapours’ passed through * Based
on the Presidential
Address (Received
to the London
for
publication
Medical
November
1971)
Society,
1970.
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the pulmonary artery and were then removed by expiration. He accepted the views of Aristotle and Erasistratus of Alexandria that blood is found in the liver and flows to the right heart, some going by the pulmonary vein to nourish the lungs, the rest diffusing through invisible pores to the left heart. Here the blood comes in contact with the ‘pneuma’ or world spirit conveyed to the left heart by the pulmonary artery to be changed into ‘vital spirit’ and circulated to the brain by the aorta and great vessels. In the brain it is changed to ‘animal spirit’ and distributed to the body through hollow nerves. Anatomy Ibn al Najs ( I 2 I 0-80) in Egypt gave a clear and lucid account of the pulmonary circulation, stating that the blood passed through the vena arteria to the lungs,
FIG.
I.
Ibn
al Nafis
( I 2 I 0-80)
FIG.
2. Marcello
Malpighi
(1628-94)
permeated the lung substance, mixed with the air and returned to the heart by the arterial veins. He denied the presence of pores in the septum of the heart. Also he described the bronchi of the lungs, and stated that ‘all these parts’ (bronchi and vessels) are associated with the loose porous flesh of the lungs. Arabic medicine then declined, and in Christendon human dissection was banned by the church. Little progress was made until the fifteenth century when Mondino De’Luui (?1275-1326), apparently the first teacher of anatomy to defy the Church, taught anatomy by human dissection. Leonardo Da Vinci (1452-r 519) is said to have dissected 30 human bodies in order to understand human anatomy and his drawings of his dissections of the diaphragm, pleural cavities and the lung substance, together with the trachea and bronchi, are an accurate record of these structures (Belt 1955). Berengario de Curpi (1460-1530) at Bologna, in his short introduction to
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anatomy, Isagogae Breves, recognized and described the importance of the chest wall, the diaphragm and the lungs, and the function of the intercostal muscles in breathing. Andreas Vesalius (I 5 14-46)) during the Renaissance, demonstrated anatomy to doctors and students in Padua. He showed, by aerating the lungs of animals with bellows, that they could be kept alive even though the chest wall was opened. Thus even at this time artificial ventilation was appreciated.
FIG.
3. A drawing
by Leonardo
da Vinci,
showing
the heart,
aorta
and
left
bronchial
arteries
William Harvey (1578-1657) firmly established our knowledge of the circulation of the blood in both the pulmonary and systemic circulation. It is interesting in Paris in 1553 described the pulmonary to note that Michael Servetus (1511-53) circulation, stating that blood enters the pulmonary artery and courses through the lungs whence the ‘sooty’ vapours are given off, and so returns by the pulmonary vein to the heart. Also about the same time Realdus Columbus ( ? 15 16-59)) Professor of Anatomy at Padua, referred to the pulmonary circulation, as did Andreas Caesalpino (1519-1603) at Pisa, who described the blood going from the inferior vena cava to the right heart, the lungs, the left heart and so to the
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arteries of the body. Harvey had learnt of the valves in the large veins from I g) and it was this that led him to his fundamental discoveries. Fubricius ( I 533-16 On 17 April 1616 he stated: ‘It is plain from the structure of the heart that the blood is passed continuously through the lungs to the aorta as by two clacks of a water bellows to raise water. It is shown by the application of a ligature that the passage of blood is from the artery into the veins. Then it follows that the movement of the blood is constantly in a circle and is brought about by the beat of the heart.’ He also worked out that the amount of blood pumped through the heart in half an hour was more than all the blood in the body-where could it come from? Where could it go to? (Harvey 1628). Marcello Malpighi ( I 628-94) discovered the capillary circulation in the lungs with the aid of a primitive microscope. He wrote two very interesting letters in which his knowledge of the anatomy of the lungs was described. He knew that
A FIG.
4. Drawings
from Marcello Malpighi’s De Pulmonibus. A, trachea attached. B, The pulmonary artery
B The lungs and vein
of the
frog
with
the
the alveoli are connected to the bronchi and trachea and the pulmonary circulation. ‘To bring certainty to the doubting mind’ he said, ‘remove the lungs from a recently living animal and by means of a syphon send water through the pulmonary artery. Thus you will wash all the blood and wash the pulmonary vessels by the water passing through them. All the lung substance, removed by the water emptied of blood, will be made pure and almost translucent.’ Malpighi also mentioned air inflation of the lungs by the trachea in order to visualize the ‘vesicles full of air’ and the lobular divisions of the lung. He noted the fragility of the arterioles and the capillary pulmonary bed : ‘Often I have seen black water, introduced by a syphon through the pulmonary artery, break out from several parts. On slight compression it used to partly sweat out from the investing membrane. Partly also to be heaped up in the intestitia, but most of it was with the blood and breaks out by the pulmonary vein. More wonderful still through the trachea, but diluted with light froth and less colour.’ Later he
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says, ‘Wherefore it is not strange of hydrops, blood spitting, phthisis, asthma and emphysema to occur in the lungs from slight cause’ (Malpighi I 66 I). Chemistry While the anatomy of the lungs and the vessels in them was being worked out, the constitution of the air was interesting chemists of the time. Two of the outstanding people of this period were Robert Boyle (1627-91) and Robert Hooke (1635-1703) at Oxford. Boyle observed that air was necessary for life as well as for combustion. Hooke experimented with a dog; the ribs and diaphragm were removed and the lung surface pricked and then, by means of two bellows, a constant stream of air was passed through the trachea and out of the lungs through the holes. He recorded : ‘This being continued for a pretty while, the dog as I expected lay still as before, his eyes moving all the time very quick, and his heart beating very regularly. But on ceasing this blast, and on suffering the lungs to fall and lay still the dog would fall into dying convulsive fits, but he is soon revived again by the renewing of the fullness of his lungs with the constant blast of fresh air.’ Joseph Priest& (1733-1804) obtained oxygen by concentrating the sun’s rays with a burning glass over mercuric oxide and observed that ‘a candle burned in the air with remarkable vigorous flame’ and he noted that this air not only supported combustion but prolonged the life of animals breathing it. He called it ‘dephlogisticated air’; it was Anton Lavoisier (I 743-94) who found oxygen and gave it its name. Nitrogen was the last of the gasses of respiration to be discovered, by Daniel Rutherford (I 749-I 8 I g) in I 772. The stage was now set for the understanding of respiration and pulmonary disease. Clinical
Signs and Pathology
Percussion of the chest as a means of investigation was recorded by Leopold Auenbrugger (I 722-1809) in I 761 but remained neglected for some time. The son of an inn-keeper, he had learnt to percuss barrels to establish the amount of wine in them and, being a musician as well, he could interpret these finer differences of percussion. He published a little book, A New Invention by Means of Percussion as a Sign of Detecting Obscure Diseases in the Interior of the Chest, having percussed the chest and then verified his findings at post mortem, but his observations remained largely unnoticed for some time. R. T. H. Laennec (1781-1826) studied at the Medical School of Nantes and then in Paris attended the hospital of La CharitC where he became interested in pathology and anatomy. At the Necker hospital direct auscultation by placing the ear on the chest wall was known and practised. Laennec was faced with an extremely obese young woman with a cardiac condition: confronted with this, he rolled a sheet of paper into a tube and placed his ear at one end and the other on the patient’s chest, and was surprised to hear the cardiac sounds and pulmonary breath sounds clearly; as a result ofthis he developed his ‘stethoscope’. He consolidated his findings using this instrument with the post mortem studies,
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and in 1818 he read before the Academy of Sciences a paper describing his new method of investigation. In 18 19 he published De I’Auscultation Mediate, in which he established the pathological interpretation of the physical signs he described. This treatise was introduced to England by Sir John Forbes who translated it and published it with a preface and notes in 182 I. William Stokes (1804-78) published a treatise on The Origin and Treatment of Diseases of the Chest in 1837, which clarified and extended the work of Laennec; this contained vivid descriptions of diseases of the larynx, trachea, bronchi, lungs and pleura. His section on bronchitis was outstanding, describing the symptoms, signs and pathology of bronchial disease.
FIG.
5. Leopold
Auenbrugger
(172~-1809)
FIG.
6. R.
T.“H.
Laennec
(1781-1826)
Physiology Galen knew that section of the cervical cord caused death from the cessation of respiration, which he had noted when physician to the gladiators of Pergamum. Little more was discovered until early in the nineteenth century when it was shown that the respiratory centre was in the medulla. The rhythm of respiration was first investigated by Herring and Breuer in 1868 who showed that the dilation of the lungs during inspiration promoted expiration and that emptying the lungs stopped expiration and initiated inspiration-the Hering-Breuer reflex. The importance of hypoxaemia and hypercapnia were just beginning to be realized. John Scott Haldane (1860-1936) made an outstanding contribution in this field; he and J. G. Priestley (188o-194.1) showed the importance of carbon dioxide in stimulating the respiratory centre. Later Haldane showed that not only CO, but also hydrogen ion concentration were of great importance. In 1925 the sino-aortic mechanism ofrespiration wasnoticed by J. F. Heymans (r8gz-) (Heymans 1929).
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That the blood changed colour in air was recognized long before oxygen was discovered. The importance of the dissociation curve for oxygen in haemoglobin was discovered by Sir Joseph Barcroft (1872-1947). Clinical spirometry was developed by Jonathan Hutchinson ( 1828-r g 13) but many years were to pass before its merits were recognized. Tuberculosis Pulmonary tuberculosis was known to the ancients. Koch (1843-rgro) discovered the tubercle bacillus in 1882 but the importance of rest and sanatorium treatment was recognized before the tubercle bacillus had been discovered. In 1840 George Bodington (1799-1882) advised treatment of tuberculosis with rest
FIG.
7. George
Bodington
(17gg-1882)
FIG.
8. Herman
Brehmer
(1826-89)
in special separate establishments, and this was followed by others advising ‘sanatorium treatment’ : Herman Brehmer (1826-89) in 1854 (Brehmer 1887) and E. L. Trudeau (1848-1915) in America in 1884 (Trudeau 1928). ‘I: F’arrier-Jones (18%194.1) (1916) envisaged the importance of patients with tuberculosis being rehabilitated: he recognized that they could work, at first for limited periods, which could gradually be increased, and that they could be paid for the work while continuing treatment at a sanatorium (Varrier-Jones 1943). Alongside this Sir Robert Phil+ (18,pIg3g), at Edinburgh, established Tuberculosis Clinics for the control of patients and the follow-up of contacts. Clinics were set up following this pattern throughout the British Isles and in most parts of the world (Philip 1937). Artificial pneumothorax was first described by C. Forlanini (r&7-1918) in 1882. Surgical treatment-phrenic evulsion, phrenic crush, adhesion division‘9
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followed a little later. Among the pioneers in surgical treatment for pulmonary tuberculosis were E. F. Su~erbncch (1875-195 I) in Berlin, the father of the thoraco-
FIG.
FIG.
g. Edward Livingstone Trudeau (1848-1915)
I I. Ernst
Ferdinand (18x-1951)
Sauerbruch
FIG.
FIG.
IO. Sir Robert (I&7-1939)
I 2. Arthur Tudor (I%o-1946)
Philip
Edwards
plasty (Sauerbruch & Schumacher I g I I), JohnAlexander in America (Alexander I 925)) 3. E. H. Roberts ( I 88 I-I 948) and Arthur Tudor Edwards ( I 890-r 946) in this country (Roberts 1935 ; Edwards 1935) and Carl Semb (1895) in Norway and
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others (Semb 1935). When the antituberculosis drugs became established safe resection of the tuberculous lung became possible. The social control of pulmonary tuberculosis by following up of contacts started by Sir Robert Philip (1857-1939) was followed by an important immunological preventative measure. In the first years of the twentieth century Albert Calmette (1863-1933) began the study of the attenuated bovine from which BCG was finally evolved; Calmette and Camille Guerin (1872-1961) worked together on this and showed that the non-virulent strain obtained, while causing a local reaction, could give an immunity to the person receiving it (Calmette et al. I 927). The disaster at Lubeck, when a large number of children were given a virulent strain of BCG vaccine instead of the attenuated one, caused many deaths. This set back the ‘protective’ approach for many years, but it was
FIG. I 3.
Carl
Semb
(1895)
FIG.
14. Thomas Bevill (1812-82)
Peacock
taken up again in Scandinavia. BCG inoculation there led to a considerable control of the incidence of pulmonary tuberculosis, particularly in young people. Later this was recognized as a very important method of protecting young people and, as the disease has become less common so immunization has become more important. In I 948 streptomycin and then PASand INAH were introduced, and many of us who remember this period did not at the time appreciate the amazing way in which these, and other drugs brought in later, would alter the whole outlook on the disease. The importance of drug-resistant bacilli was first recognized in 1952. At first it was thought to be an acquired resistance, later it was shown to be due to mutants growing out. Immunology
Hippocrates (460 B.C.) recognized ‘spasmodic asthma’ and Bernard Ramazzini (1633-17 14) noted ‘diseases of sifters and measurers of grain’. He describes how
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damp, stored cereals become overheated and crumble to dust. The workers ‘heap a thousand curses on their calling’; and well they might, for they died young of what was clearly right heart failure, resulting from their lung disease. This is a good description of the circumstances of what is now called farmer’s lung. John Bostock (I 773-1846) d escribed a ‘case of periodical affection of the eyes and chest’, occurring in mid-June or early July, before the Royal Medical Chirurgical Society of London. This was clearly allergy to grass pollens, and he himself was the patient. John Elliotson (1791-1868) attributed this seasonal disturbance to grass pollens, and this was later confirmed by Blackley. Henr_y Hyde Salter (1823~71), himself an asthmatic, wrote On Asthma, its Pathology and Treatment (1860). He recognized the production of asthma and other upper respiratory reactions by foods and animal emanations. Charles Black&v (r82o-rgoo) in Manchester, sent up kites into the sky with glass slides upon them (1873). He showed the presence of pollen grains, with the highest count in June-July, corresponding with our present grass pollen season, and he explained the seasonal symptoms of his patients in this way. He also performed nasal, bronchial and skin tests with pollen grains, many on himself, and elicited the signs and symptoms of hay fever, asthma and wealing skin reactions. In one experiment he produced symptoms with one grain of pollen applied to the fauces. C. R. Richet (1850-1925) described anaphylaxis, ‘without protection’ (in contrast to ‘prophylaxis’), and increased reactivity as in asthma. 8. M. Arthus (1862-1945) showed (1903) the importance of precipitins in the reaction which now carries his name. Clement van Pirquet (1874-1929) introduced the term ‘allergy’, an ‘acquired, specific, altered capacity to react’. L. Noon (1878-r gr3), at St Mary’s Hospital, introduced grass pollen vaccine for hay fever and asthma. Sir Henry Dale (1875-1968) showed the role of histamine and its release in allergic reactions. C. W. Prausnite and IX Kustner demonstrated the passive transfer of skin sensitizing (reaginic) antibody in I 92 I. A. F. Coca introduced the term ‘atopy’ (strange disease) in 1925 to describe those subjects who develop hay fever, asthma and often have infantile eczema. Reaginic antibodies are responsible for the respiratory symptoms. Storm van Leewen (1882-1933) in Holland described the role of fungal spores in respiratory allergy with J. M. Campbell (I gp) who described farmer’s lung in Britain. Industrial
G. B. Agricola (1494-1555)
Lung
Disease
strongly advocated the ventilation of mines in 1556, having noted the dyspnoea of mine workers and linked it with the dusty atmosphere in which they worked. This was as a result of his interest in the mines at Jaochimtal in Bohemia, and he also mentioned ‘corrosive dusts’
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which ulcerated the lungs and cause consumption, and relates that there were women who had married seven husbands In 1672 Isbrand van Diemerbroek (1609-I 674), Professor of Medicine at Utrecht, described some stone cutters who died of asthma and that their lungs at post mortem cut like cutting through a mass of sand. B. Ramasz$ni
FIG. 15. The
title
page
of Charles
H.
Blackley’s
monograph
(1633-1714) d escribed in I 7 I 3 how stone cutters breathe in small particles and turn asthmatic and consumptive. J. Johnstone (1799) pointed out the high mortality rate among needle pointers at Redditch and Arnold Knight (1819) suggested that criminals should be employed in dry grinding because of the mortality. G. 1. Thackrah (1793-1833) looked into these industries and recognized that sandstone dust was dangerous, while limestone dust was not. Bricklayers
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and lime workers were long lived, but sandstone masons died early. He also noted the association between dust inhalation and pulmonary tuberculosis; at the time he also noted that chest disease occurred in men filing off iron castings to remove burnt-on sand. G. Culvert Holland (1801-65)) a physician to the Sheffield General Infirmary, observed the workers in grinding in Sheffield, and noted their work was done with a dry stone and that there was much dust in the atmosphere and found that of 97 men 30 were suffering from grinder’s asthma, and that of the 61 people who had died in 15 years, 35 were under the age of 30 years. C. T. Thackrah (1793-1833) recognized that collierymen were liable to develop miner’s asthma and in 1857 Cox described the disease as the ‘scourge of the miners’. In the early days chest disease was commonly named according to the occupation which caused it, such as grinder’s asthma, grinder’s consumption, mason’s disease, miner’s asthma, miner’s phthisis and stonemason’s disease. Phthisis was, indeed, a common complication. Indeed, in 1915 F. L. CoZZis(1870-1957) pointed to the high mortality from pulmonary tuberculosis in flint knappers in a Suffolk village. Thomas Bem’ll Peacock (18 I 2-82)) a physician at St Thomas’s and the London Chest Hospital, and E. H. Greenhow (1814-88), at the Middlesex Hospital, established the existence of miner’s disease as an entity and distinguished it from pulmonary tuberculosis. In 1860-1 Greenhow carried out a large field survey in many industries, and in the Transaction of the Pathological Societ_vof London (1860 and 1866) there are descriptions of this condition by both these physicians. They found silica in the lungs by examining them under polarized light (Peacock 1860 ; Greenhow 1964-g). The disease was called silicosis by Visconti in 1870. The early part of the twentieth century worldwide interest in this disease developed with the work of J. S. Haldane (1860-1936) in miners (agog) and quarry workers (I gr 2) (Haldane agog, rgr 2) and the Commission on Miners’ Phthisis in South Africa (Miners’ Phthisis Prevention Committee 1913). After mechanization of mines the amount of dust increased. M. J. Stewart and J. S. Faulds (I 934) pointed out that haematite mining was safe until the introduction of the pneumatic drill in rgr 3. All these observations resulted in the introduction of laws defining the maximum amount of dust permissible in the air of the mines, and technical innovations in ventilation and dust suppression. While the use of asbestos in industry is modern, it is of interest to note that it has been known for over 2000 years, and Herodotus (450 B.C.) relates how the Romans mined it in Italy for enshrouding of corpses before cremation, so their ashes for burial could easily be collected. Pliny (A.D. 80) confirms the difficulty in working asbestos and refers to the use of respirators to avoid inhaling the dusts. Strabo (30 B.C.) and Plutarch (A.D. 70) refer to the wicks of the lamps of vestal virgins as ‘asbasta’, the unquenchable inextinguishable wick. Charlemagne had a tablecloth of asbestos which was cleaned by passing through fire. The first case of pulmonary asbestosis recorded in Great Britain was published by M. Murray in 1907; the patient died in Charing Cross Hospital with extensive pulmonary fibrosis. The relationship between asbestos and pulmonary
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fibrosis was established in 1928. This led to the report of E. R. A. Merewether and C. W. Price in 1980, and similar reports from Germany. Between 1930 and 1934 cases occurring at the Cape Asbestos factory were investigated by S. R. Gloyne (r882-1950) and W. Burton Wood (1884-1943) at the London Chest Hospital (Wood & Gloyne 1930) and D. Hunter at the London Hospital (Hunter I 955). Gloyne later pointed out the frequent association of pulmonary neoplasms with asbestos (Gloyne 195 I). These then are perhaps the most important stepping stones in the history of chest medicine up to the beginning of the modern era. ACKNOWLEDGEMENTS
The illustrations for this of Diseases of the Chest.
article
were
kindly
supplied
by Mr
Bishop,
Librarian
of the
Institute
BIBLIOGRAPHY
AGRICOLA, GEORGKJS (1912) De Re Metallica. Book I. Translated from first Latin edition of 1556 by H. C. Hoover and L. H. Hoover. San Francisco: Mining and Scientific Press. ARTHUS, N. M. (1903) Injections repettes de serum de cheval chez le lapin. C.r. Se’anc. Sot. biol. Paris, 55, 817. ALEXANDER, J. (1925) The Surgery of Pulmonary Tuberculosis. Philadelphia and New York: Lea and Febiger. AUENBRUGGER, LEOPOLD (1761) Inventurn Novum ex Percussione Thoracic Humani, etc. Vienna: J. T. Trattner (English translation by Sir John Forbes, London, 1824). BARCROFT, SIR JOSEPH (1925-8) The Respiratory Function of the Blood. Cambridge: Cambridge University Press. BELT, E. (1955) Leonardo the Anatomist, p. 30. Kansas: University of Kansas Press. BERENGARIO DA CARPI, J. (1959) A Short Introduction to Anatomy, 1523 and 1535 editions, translated by L. R. Lind, p. 88. Chicago: University of Chicago Press. BLACKLEY, C. H. (1873) Experimental Researches on the Causes and Nature of Catarrhus Aestivus. London: Bailliere, Tindall & Cox. BODINGTON, G. (1840) Essay on the Treatment and Cure of Pulmonav Consumption. London: Longmans. BOSTOCK, J. (I 8 I g) Case of periodical affection of the eyes and chest. Med.-chir. Trans., IO, I 6 I. BOYLE, R., Cited by Perkins, J. F. (x964). BREHMER, H. (1887) Die Therapie der Chronischen Lungenschwindsucht. Wiesbaden: Bergmann. BREUER, J. (1868) Die Selbststeuerung der Athmung durch den Nervus vagus. Sker. Acad. Wiss. Wien, math. nat., 58, gog. BRYAN, A. M. (1950) Report ofInspector of Minesfor rg48. London: H.M.S.O. CALMETTE, L. C. A., GUERIN, C., NEGRE, L. & BOQUET, A. (1927) Sur la vaccination preventive des enfants nouveau-& contra la tuberculose par le B.C.G. Ann. Inst. Pasteur, 41, 201. CAMPBELL, J. M. (1932) Acute symptoms following work with hay. Br. med. J., ii, I 143. COCA, A. F. & GROVE, E. F. (1925) Studies in hypersensitiveness. XIII. A study of the atopic reagins. J. Immunol., 10, 445. COLLIS, E. L. (1915) Industrial Pneumoconiosis with Special Reference to Dust Phthisis. London: H.M.S.O. Cox, W. I. (1857) Diseases of colliers in South Lancashire. Br. med. J., 425,491, 579. DALE, SIR HENRY & RICHARDS, A. N. (1918-19) The vaso-dilator action of histamine and of some other substances. J. Physiol., Lond., 52, I IO. DIEMERBROCK, ISBRAND VAN (I 672) Anatome Corporis Humani, etc., p. 306, Ultrajecti: Meinardi a Dreunen.
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EDWARDS, A. T. (1985) The place of surgery in chest disease. Practitioner, 134, 14. ELLIOTSON, J. (1831-33) Hay fever. Lond. med. Gaz., 8, 41 I ; 12, 164. FORLANINI, C. (1882) A contribuzione della terapia chirurgica della tisi ablazione de1 polone? Pneumotarace artificiale? GaZz. 0~. C&z., 3, 537. Fox, W. (1962) The chemotherapy and epidemiology of tuberculosis. Some findings of general applicability from the Tuberculosis Chemotherapy Centre, Madras. Lance& ii, 413, 473. GALEN, CLAUDIUS, Cited by Perkins, J. F. (1964). GLOYNE, S. R. (1951) Pneumoconiosis. A histological survey of necropsy material in 1205 cases. Lance& i, 810. GOTTLIEB, L. S. (1964) A History of Respiration. Springfield, Ill.: Charles C. Thomas. GREENHOW, E. H. (1864-g) Cases illustrating the pathology of the pulmonary disease frequent among razor-grinders, stoneworkers, colliers etc. (I st, 2nd & 3rd series). Trans. Path. Sot. Lond., 16, 57; 17, 24; 20, 41. HALDANE, J. S. (1909) In Second Retort of the Royal Commission on Mines (Cd. 4820). London: H.M.S.O. HALDANE, J. S. (19x2) Royal Commission on Metall$erous Mines and Quarries. First Refiort of the Commissioners (Cd. 638g), vol. I. London: H.M.S.O. HALDANE, J. S. & PRIESTLEY, J. G. (1922) Resfiiration. New Haven: Yale University Press. HARVEY, W. (I 628) De Motu Cordis, etc. William Fitzer. Frankfurt. (Translated from the original Latin by K. J. Franklin, Blackwell Scientific Publications, Oxford, 1957.) HERING, K. E. K. (1868) Die Selbststeuerung der Athmung durch den Nervus vagus. Sber. Akad. Wiss. Wien., math.-nut., 57, 672. HERODOTUS, Cited by Hunter, D. (1955). H&YMANS, C. (1929) Le sinus carotidien et la zone homologue cardio-aortique. Paris: Presses Universitaires de France. HIPPOCRATES, The Genuine Works of Hippocrates. Translated by Francis Adams. London: Sydenham Society. HOLLAND, G. C. (1843) Diseases of the Lungs from Mechanical Causes and Inquiries into the Condition of the Artisans Eqbosed to the Inhalation of Dust. London : John Churchill. HOOKE, R., Cited by Perkins, J. F. (1964). HUNTER, D. (1955) The Diseases of Occujations, p. 877. London: English Universities Press. IBN AL NAFIS, Cited by Gottlieb, L. S. (1964). JOHNSTONE, J. (1799) Some account of a species of phthisis pulmonaris peculiar to persons occupied in pointing needles. Mem. Lond. Med. Sot., 5, 89. KNIGHT, A. (1819) Cited by Hunter, D. (1955). KOCH (I 882) Die Aetiologie der Tuberkulose. Berl. klin. Wschr., 19, 22 I. LAENNEC, R. T. H. (1819) De l’dusculation Mediate, etc. Paris: Brossen et Chaude. (English translation by Sir John Forbes, London, 1821.) LAVOISIER, A. L., Cited by Perkins, J. F. (1964). LEE LANDER, F. P. & DAVIDSON, M. (I 988) The pathogenesis of bronchiectasis. Br. med. J., i, I 047. MALPIGHI, M. (1661) De Pulmonibus. Bologna. (Translated by J. Young (Igrg-80) Proc. R. SOL. Med., 23, I.) MERE~ETHER, E. R. A. & PRICE, C. W. (1930) Refort on E$ects of Asbestos Dust on the Lungs and Dust Su&wession in the Asbestos Industry. London: H.M.S.O. MINERS’ PHTHISIS PREVENTION COMMITTEE (1912) Preliminary Report of the Miners’ Phthisis Prevention Committee (I g I 2). Cape Town. MURRAY, M. (I 907) Departmental Committee on Compensationfor Industrial Disease. Cmd. 3494, p. 14; Cmd. 8495, p. 127. London: H.M.S.O. NOON, L. ( I~I I) Prophylactic inoculation against hay fever. Lance& i, 1572. PEACOCK, T. B. (1860) On French millstone-makers’ phthisis. Br. For. med.-chir. Rev., 25, 2 14. PERKINS, J. F. (1964) Historical development of respiratory physiology, in Handbook of Physiology. Respiration I, ed. W. 0. Fenn and H. Rahn. Washington : American Physiology Society. PHILIP, SIR ROBERT (1937) Collected Pafiers on Tuberculosis. London: Oxford University Press. PIRQUET, C. P. (1907) Klinische Studien iiber Vakzination und Vakzinale Allergic. Leipzig und Wien: F. Deuticke.
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PLINIUS SECONDUS, CAIUS, Cited by Hunter, D. (1955). PLUTARCH, Cited by Hunter, D. ( 1955). PRAUSNITZ, C. W. & KUSTNER, H. (I g2 I) Studien uber die Ueberempfindlichkeit. zeentbl. Bakt. Parasitkde, 86, I 60. PRIESTLEY, J., Cited by Perkins, J. F. (1964). RAMAZZINI, B. (1700) De Morbe Ar@cum Diatriba. Mutinae: A. Capponi. (Revised with translations and notes by W. C. Wright, University of Chicago Press, Chicago, 1940.) RICHET, C. R. (1907-8) De l’anaphylaxie en general et de l’anaphylaxie par la mytilocongestine en particulier. Ann. Inst. Pasteur, 21, 497; 22, 465. ROBERTS, J. E. H. (1935) The surgery of pleural and pulmonary infections (Lettsomian Lectures). Trans. med. Sot. Lond., 58, 183. RBNTGEN, W. K. (1895) Ueber eine neue Art von Strahlen. Sber. phys.-med. Ges. Wiirzb., 132. SALTER, H. H. (1860) On Asthma, Its Pathology and Treatment. London: John Churchill. SAUERBRUCH, E. & SCHUMACHER, E. D. (1911) Technik der Thoraxchirurgie. Berlin: Julius Springer. SEMB, C. B. (1935) Thoracoplasty with extrafascial apicolysis. Acta chir. stand., Suppl. 37. SERVETUS, M. (I 553) Christianismi Restitutie. Vienna (see Michael Serve&s: A Translation of his Geographical, Medical and Astrological Writings with Introductions and Notes, by C. D. O’Malley, American Philosophical Society, Philadelphia,. STEWART, M. J. & FAULDS, J. S. (1934) The pulmonary fibrosis of haematite miners. J. Path. Bact., 39, 233. STOKES, W. (1837) A Treatise on the Diagnosis and Treatment of Diseases of the Chest, etc. Dublin: Hodges and Smith. (London: New Sydenham Society, 1882.) STORM VAN LEEUWEN, W. (1925) Allergic Diseases; Diagnosis and Treatment of Bronchial Asthma, Hay-fever and Other Allergic Diseases. Philadelphia: Lippincott. STRABE, Cited by Hunter, D. (I 953). THACKRAH, C. T. (1831) The Effects of the Principal Arts, Trades and Professions, and of Civic States and Habits of Living on Health and Longevity. London: Longmans. TRUDEAU, E. L. (1928) An Autobiography. New York: National Tuberculosis Association. VARRIER-JONES, SIR PENDRILL (I 943) Papers of a Pioneer. London: Hutchinson. VESALIUS, A., Cited by Gottlieb, L. S. (1964). VISCONTI (1870) Cited by Hunter, D. (1955). WAGNER, J. C., SLEGGS, C. A. & MARCHAND, P. (1960) Diffuse pleural mesothelioma and asbestos exposure in the North Western Cape Province. Br. J. indust. Med., 17, 260. WOOD, W. B. & GLOYNE, S. R. (1930) Pulmonary asbestosis. Lance& i, 445.
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J. Dis.
STEPPING STONES IN THE OF CHEST MEDICINE*
Chest
(1972)
66, 207
HISTORY
J- SMART The
London
Chest
Hospital
and
Brompton
Hospital,
London
history of medicine falls naturally into three main periods: ancient times until Galen and his work in the second century A.D. ; then, after the seven or eight hundred years of the Dark Ages, the period of awakening of understanding of anatomy and physiology from the thirteenth to the seventeenth century; and finally the period of scientific medicine when the chemistry of air and the physiological principles of respiration became established.
THE
Ancient
Times
The vital importance of breathing was obvious to the ancients and they endowed ‘breath’ with supernatural and magical powers. There was an understanding of its destination, however. In one of the Egyptian medical papyri it was recorded that ‘the breath and the spirit enter the nose and go to the heart and lungs which then distributes it to the whole body’. We owe to Hippocrates (460-315 B.C.) the insistence on high medical standards and the introduction of the systematic inductive procedure for unravelling the complexities of disease. He believed in the doctrine of the four humours-blood, phlegm, yellow bile and black bile-controlling human constitution according to the proportions in which they were present; he described pneumonia and knew something of auscultation of the chest, describing succusion sounds and friction rub. Philosophers such as Aristotle and Diogenes thought that arteries normally contained air. One of the earlier records of the anatomy of the lungs and great vessels comes from the Alexandrian school around 300 B.C. where human dissection was practised: Hprophilus is said to have introduced the terms vena arterialis to describe the vessel leading from the right side of the heart to the lungs (pulmonary artery) and arteria venalis to describe the pulmonary vein. Claudius Galen (A.D. 130~zoo), of Pergamum in Asia Minor, dominated medical teaching for nearly fourteen centuries. He postulated two types of blood -one produced by the heart and the other by the liver. The blood from the liver had to be ‘vitalized’ and this was achieved by its diffusing through the septum of the heart thereby becoming purified. The ‘fuliginous vapours’ passed through * Based
on the Presidential
Address (Received
to the London
for
publication
Medical
November
1971)
Society,
1970.
SMART
208
the pulmonary artery and were then removed by expiration. He accepted the views of Aristotle and Erasistratus of Alexandria that blood is found in the liver and flows to the right heart, some going by the pulmonary vein to nourish the lungs, the rest diffusing through invisible pores to the left heart. Here the blood comes in contact with the ‘pneuma’ or world spirit conveyed to the left heart by the pulmonary artery to be changed into ‘vital spirit’ and circulated to the brain by the aorta and great vessels. In the brain it is changed to ‘animal spirit’ and distributed to the body through hollow nerves. Anatomy Ibn al Najs ( I 2 I 0-80) in Egypt gave a clear and lucid account of the pulmonary circulation, stating that the blood passed through the vena arteria to the lungs,
FIG.
I.
Ibn
al Nafis
( I 2 I 0-80)
FIG.
2. Marcello
Malpighi
(1628-94)
permeated the lung substance, mixed with the air and returned to the heart by the arterial veins. He denied the presence of pores in the septum of the heart. Also he described the bronchi of the lungs, and stated that ‘all these parts’ (bronchi and vessels) are associated with the loose porous flesh of the lungs. Arabic medicine then declined, and in Christendon human dissection was banned by the church. Little progress was made until the fifteenth century when Mondino De’Luui (?1275-1326), apparently the first teacher of anatomy to defy the Church, taught anatomy by human dissection. Leonardo Da Vinci (1452-r 519) is said to have dissected 30 human bodies in order to understand human anatomy and his drawings of his dissections of the diaphragm, pleural cavities and the lung substance, together with the trachea and bronchi, are an accurate record of these structures (Belt 1955). Berengario de Curpi (1460-1530) at Bologna, in his short introduction to
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anatomy, Isagogae Breves, recognized and described the importance of the chest wall, the diaphragm and the lungs, and the function of the intercostal muscles in breathing. Andreas Vesalius (I 5 14-46)) during the Renaissance, demonstrated anatomy to doctors and students in Padua. He showed, by aerating the lungs of animals with bellows, that they could be kept alive even though the chest wall was opened. Thus even at this time artificial ventilation was appreciated.
FIG.
3. A drawing
by Leonardo
da Vinci,
showing
the heart,
aorta
and
left
bronchial
arteries
William Harvey (1578-1657) firmly established our knowledge of the circulation of the blood in both the pulmonary and systemic circulation. It is interesting in Paris in 1553 described the pulmonary to note that Michael Servetus (1511-53) circulation, stating that blood enters the pulmonary artery and courses through the lungs whence the ‘sooty’ vapours are given off, and so returns by the pulmonary vein to the heart. Also about the same time Realdus Columbus ( ? 15 16-59)) Professor of Anatomy at Padua, referred to the pulmonary circulation, as did Andreas Caesalpino (1519-1603) at Pisa, who described the blood going from the inferior vena cava to the right heart, the lungs, the left heart and so to the
210
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arteries of the body. Harvey had learnt of the valves in the large veins from I g) and it was this that led him to his fundamental discoveries. Fubricius ( I 533-16 On 17 April 1616 he stated: ‘It is plain from the structure of the heart that the blood is passed continuously through the lungs to the aorta as by two clacks of a water bellows to raise water. It is shown by the application of a ligature that the passage of blood is from the artery into the veins. Then it follows that the movement of the blood is constantly in a circle and is brought about by the beat of the heart.’ He also worked out that the amount of blood pumped through the heart in half an hour was more than all the blood in the body-where could it come from? Where could it go to? (Harvey 1628). Marcello Malpighi ( I 628-94) discovered the capillary circulation in the lungs with the aid of a primitive microscope. He wrote two very interesting letters in which his knowledge of the anatomy of the lungs was described. He knew that
A FIG.
4. Drawings
from Marcello Malpighi’s De Pulmonibus. A, trachea attached. B, The pulmonary artery
B The lungs and vein
of the
frog
with
the
the alveoli are connected to the bronchi and trachea and the pulmonary circulation. ‘To bring certainty to the doubting mind’ he said, ‘remove the lungs from a recently living animal and by means of a syphon send water through the pulmonary artery. Thus you will wash all the blood and wash the pulmonary vessels by the water passing through them. All the lung substance, removed by the water emptied of blood, will be made pure and almost translucent.’ Malpighi also mentioned air inflation of the lungs by the trachea in order to visualize the ‘vesicles full of air’ and the lobular divisions of the lung. He noted the fragility of the arterioles and the capillary pulmonary bed : ‘Often I have seen black water, introduced by a syphon through the pulmonary artery, break out from several parts. On slight compression it used to partly sweat out from the investing membrane. Partly also to be heaped up in the intestitia, but most of it was with the blood and breaks out by the pulmonary vein. More wonderful still through the trachea, but diluted with light froth and less colour.’ Later he
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says, ‘Wherefore it is not strange of hydrops, blood spitting, phthisis, asthma and emphysema to occur in the lungs from slight cause’ (Malpighi I 66 I). Chemistry While the anatomy of the lungs and the vessels in them was being worked out, the constitution of the air was interesting chemists of the time. Two of the outstanding people of this period were Robert Boyle (1627-91) and Robert Hooke (1635-1703) at Oxford. Boyle observed that air was necessary for life as well as for combustion. Hooke experimented with a dog; the ribs and diaphragm were removed and the lung surface pricked and then, by means of two bellows, a constant stream of air was passed through the trachea and out of the lungs through the holes. He recorded : ‘This being continued for a pretty while, the dog as I expected lay still as before, his eyes moving all the time very quick, and his heart beating very regularly. But on ceasing this blast, and on suffering the lungs to fall and lay still the dog would fall into dying convulsive fits, but he is soon revived again by the renewing of the fullness of his lungs with the constant blast of fresh air.’ Joseph Priest& (1733-1804) obtained oxygen by concentrating the sun’s rays with a burning glass over mercuric oxide and observed that ‘a candle burned in the air with remarkable vigorous flame’ and he noted that this air not only supported combustion but prolonged the life of animals breathing it. He called it ‘dephlogisticated air’; it was Anton Lavoisier (I 743-94) who found oxygen and gave it its name. Nitrogen was the last of the gasses of respiration to be discovered, by Daniel Rutherford (I 749-I 8 I g) in I 772. The stage was now set for the understanding of respiration and pulmonary disease. Clinical
Signs and Pathology
Percussion of the chest as a means of investigation was recorded by Leopold Auenbrugger (I 722-1809) in I 761 but remained neglected for some time. The son of an inn-keeper, he had learnt to percuss barrels to establish the amount of wine in them and, being a musician as well, he could interpret these finer differences of percussion. He published a little book, A New Invention by Means of Percussion as a Sign of Detecting Obscure Diseases in the Interior of the Chest, having percussed the chest and then verified his findings at post mortem, but his observations remained largely unnoticed for some time. R. T. H. Laennec (1781-1826) studied at the Medical School of Nantes and then in Paris attended the hospital of La CharitC where he became interested in pathology and anatomy. At the Necker hospital direct auscultation by placing the ear on the chest wall was known and practised. Laennec was faced with an extremely obese young woman with a cardiac condition: confronted with this, he rolled a sheet of paper into a tube and placed his ear at one end and the other on the patient’s chest, and was surprised to hear the cardiac sounds and pulmonary breath sounds clearly; as a result ofthis he developed his ‘stethoscope’. He consolidated his findings using this instrument with the post mortem studies,
SMART
212
and in 1818 he read before the Academy of Sciences a paper describing his new method of investigation. In 18 19 he published De I’Auscultation Mediate, in which he established the pathological interpretation of the physical signs he described. This treatise was introduced to England by Sir John Forbes who translated it and published it with a preface and notes in 182 I. William Stokes (1804-78) published a treatise on The Origin and Treatment of Diseases of the Chest in 1837, which clarified and extended the work of Laennec; this contained vivid descriptions of diseases of the larynx, trachea, bronchi, lungs and pleura. His section on bronchitis was outstanding, describing the symptoms, signs and pathology of bronchial disease.
FIG.
5. Leopold
Auenbrugger
(172~-1809)
FIG.
6. R.
T.“H.
Laennec
(1781-1826)
Physiology Galen knew that section of the cervical cord caused death from the cessation of respiration, which he had noted when physician to the gladiators of Pergamum. Little more was discovered until early in the nineteenth century when it was shown that the respiratory centre was in the medulla. The rhythm of respiration was first investigated by Herring and Breuer in 1868 who showed that the dilation of the lungs during inspiration promoted expiration and that emptying the lungs stopped expiration and initiated inspiration-the Hering-Breuer reflex. The importance of hypoxaemia and hypercapnia were just beginning to be realized. John Scott Haldane (1860-1936) made an outstanding contribution in this field; he and J. G. Priestley (188o-194.1) showed the importance of carbon dioxide in stimulating the respiratory centre. Later Haldane showed that not only CO, but also hydrogen ion concentration were of great importance. In 1925 the sino-aortic mechanism ofrespiration wasnoticed by J. F. Heymans (r8gz-) (Heymans 1929).
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That the blood changed colour in air was recognized long before oxygen was discovered. The importance of the dissociation curve for oxygen in haemoglobin was discovered by Sir Joseph Barcroft (1872-1947). Clinical spirometry was developed by Jonathan Hutchinson ( 1828-r g 13) but many years were to pass before its merits were recognized. Tuberculosis Pulmonary tuberculosis was known to the ancients. Koch (1843-rgro) discovered the tubercle bacillus in 1882 but the importance of rest and sanatorium treatment was recognized before the tubercle bacillus had been discovered. In 1840 George Bodington (1799-1882) advised treatment of tuberculosis with rest
FIG.
7. George
Bodington
(17gg-1882)
FIG.
8. Herman
Brehmer
(1826-89)
in special separate establishments, and this was followed by others advising ‘sanatorium treatment’ : Herman Brehmer (1826-89) in 1854 (Brehmer 1887) and E. L. Trudeau (1848-1915) in America in 1884 (Trudeau 1928). ‘I: F’arrier-Jones (18%194.1) (1916) envisaged the importance of patients with tuberculosis being rehabilitated: he recognized that they could work, at first for limited periods, which could gradually be increased, and that they could be paid for the work while continuing treatment at a sanatorium (Varrier-Jones 1943). Alongside this Sir Robert Phil+ (18,pIg3g), at Edinburgh, established Tuberculosis Clinics for the control of patients and the follow-up of contacts. Clinics were set up following this pattern throughout the British Isles and in most parts of the world (Philip 1937). Artificial pneumothorax was first described by C. Forlanini (r&7-1918) in 1882. Surgical treatment-phrenic evulsion, phrenic crush, adhesion division‘9
SMART
214
followed a little later. Among the pioneers in surgical treatment for pulmonary tuberculosis were E. F. Su~erbncch (1875-195 I) in Berlin, the father of the thoraco-
FIG.
FIG.
g. Edward Livingstone Trudeau (1848-1915)
I I. Ernst
Ferdinand (18x-1951)
Sauerbruch
FIG.
FIG.
IO. Sir Robert (I&7-1939)
I 2. Arthur Tudor (I%o-1946)
Philip
Edwards
plasty (Sauerbruch & Schumacher I g I I), JohnAlexander in America (Alexander I 925)) 3. E. H. Roberts ( I 88 I-I 948) and Arthur Tudor Edwards ( I 890-r 946) in this country (Roberts 1935 ; Edwards 1935) and Carl Semb (1895) in Norway and
SOME
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STONES
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HISTORY
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others (Semb 1935). When the antituberculosis drugs became established safe resection of the tuberculous lung became possible. The social control of pulmonary tuberculosis by following up of contacts started by Sir Robert Philip (1857-1939) was followed by an important immunological preventative measure. In the first years of the twentieth century Albert Calmette (1863-1933) began the study of the attenuated bovine from which BCG was finally evolved; Calmette and Camille Guerin (1872-1961) worked together on this and showed that the non-virulent strain obtained, while causing a local reaction, could give an immunity to the person receiving it (Calmette et al. I 927). The disaster at Lubeck, when a large number of children were given a virulent strain of BCG vaccine instead of the attenuated one, caused many deaths. This set back the ‘protective’ approach for many years, but it was
FIG. I 3.
Carl
Semb
(1895)
FIG.
14. Thomas Bevill (1812-82)
Peacock
taken up again in Scandinavia. BCG inoculation there led to a considerable control of the incidence of pulmonary tuberculosis, particularly in young people. Later this was recognized as a very important method of protecting young people and, as the disease has become less common so immunization has become more important. In I 948 streptomycin and then PASand INAH were introduced, and many of us who remember this period did not at the time appreciate the amazing way in which these, and other drugs brought in later, would alter the whole outlook on the disease. The importance of drug-resistant bacilli was first recognized in 1952. At first it was thought to be an acquired resistance, later it was shown to be due to mutants growing out. Immunology
Hippocrates (460 B.C.) recognized ‘spasmodic asthma’ and Bernard Ramazzini (1633-17 14) noted ‘diseases of sifters and measurers of grain’. He describes how
216
SMART
damp, stored cereals become overheated and crumble to dust. The workers ‘heap a thousand curses on their calling’; and well they might, for they died young of what was clearly right heart failure, resulting from their lung disease. This is a good description of the circumstances of what is now called farmer’s lung. John Bostock (I 773-1846) d escribed a ‘case of periodical affection of the eyes and chest’, occurring in mid-June or early July, before the Royal Medical Chirurgical Society of London. This was clearly allergy to grass pollens, and he himself was the patient. John Elliotson (1791-1868) attributed this seasonal disturbance to grass pollens, and this was later confirmed by Blackley. Henr_y Hyde Salter (1823~71), himself an asthmatic, wrote On Asthma, its Pathology and Treatment (1860). He recognized the production of asthma and other upper respiratory reactions by foods and animal emanations. Charles Black&v (r82o-rgoo) in Manchester, sent up kites into the sky with glass slides upon them (1873). He showed the presence of pollen grains, with the highest count in June-July, corresponding with our present grass pollen season, and he explained the seasonal symptoms of his patients in this way. He also performed nasal, bronchial and skin tests with pollen grains, many on himself, and elicited the signs and symptoms of hay fever, asthma and wealing skin reactions. In one experiment he produced symptoms with one grain of pollen applied to the fauces. C. R. Richet (1850-1925) described anaphylaxis, ‘without protection’ (in contrast to ‘prophylaxis’), and increased reactivity as in asthma. 8. M. Arthus (1862-1945) showed (1903) the importance of precipitins in the reaction which now carries his name. Clement van Pirquet (1874-1929) introduced the term ‘allergy’, an ‘acquired, specific, altered capacity to react’. L. Noon (1878-r gr3), at St Mary’s Hospital, introduced grass pollen vaccine for hay fever and asthma. Sir Henry Dale (1875-1968) showed the role of histamine and its release in allergic reactions. C. W. Prausnite and IX Kustner demonstrated the passive transfer of skin sensitizing (reaginic) antibody in I 92 I. A. F. Coca introduced the term ‘atopy’ (strange disease) in 1925 to describe those subjects who develop hay fever, asthma and often have infantile eczema. Reaginic antibodies are responsible for the respiratory symptoms. Storm van Leewen (1882-1933) in Holland described the role of fungal spores in respiratory allergy with J. M. Campbell (I gp) who described farmer’s lung in Britain. Industrial
G. B. Agricola (1494-1555)
Lung
Disease
strongly advocated the ventilation of mines in 1556, having noted the dyspnoea of mine workers and linked it with the dusty atmosphere in which they worked. This was as a result of his interest in the mines at Jaochimtal in Bohemia, and he also mentioned ‘corrosive dusts’
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which ulcerated the lungs and cause consumption, and relates that there were women who had married seven husbands In 1672 Isbrand van Diemerbroek (1609-I 674), Professor of Medicine at Utrecht, described some stone cutters who died of asthma and that their lungs at post mortem cut like cutting through a mass of sand. B. Ramasz$ni
FIG. 15. The
title
page
of Charles
H.
Blackley’s
monograph
(1633-1714) d escribed in I 7 I 3 how stone cutters breathe in small particles and turn asthmatic and consumptive. J. Johnstone (1799) pointed out the high mortality rate among needle pointers at Redditch and Arnold Knight (1819) suggested that criminals should be employed in dry grinding because of the mortality. G. 1. Thackrah (1793-1833) looked into these industries and recognized that sandstone dust was dangerous, while limestone dust was not. Bricklayers
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and lime workers were long lived, but sandstone masons died early. He also noted the association between dust inhalation and pulmonary tuberculosis; at the time he also noted that chest disease occurred in men filing off iron castings to remove burnt-on sand. G. Culvert Holland (1801-65)) a physician to the Sheffield General Infirmary, observed the workers in grinding in Sheffield, and noted their work was done with a dry stone and that there was much dust in the atmosphere and found that of 97 men 30 were suffering from grinder’s asthma, and that of the 61 people who had died in 15 years, 35 were under the age of 30 years. C. T. Thackrah (1793-1833) recognized that collierymen were liable to develop miner’s asthma and in 1857 Cox described the disease as the ‘scourge of the miners’. In the early days chest disease was commonly named according to the occupation which caused it, such as grinder’s asthma, grinder’s consumption, mason’s disease, miner’s asthma, miner’s phthisis and stonemason’s disease. Phthisis was, indeed, a common complication. Indeed, in 1915 F. L. CoZZis(1870-1957) pointed to the high mortality from pulmonary tuberculosis in flint knappers in a Suffolk village. Thomas Bem’ll Peacock (18 I 2-82)) a physician at St Thomas’s and the London Chest Hospital, and E. H. Greenhow (1814-88), at the Middlesex Hospital, established the existence of miner’s disease as an entity and distinguished it from pulmonary tuberculosis. In 1860-1 Greenhow carried out a large field survey in many industries, and in the Transaction of the Pathological Societ_vof London (1860 and 1866) there are descriptions of this condition by both these physicians. They found silica in the lungs by examining them under polarized light (Peacock 1860 ; Greenhow 1964-g). The disease was called silicosis by Visconti in 1870. The early part of the twentieth century worldwide interest in this disease developed with the work of J. S. Haldane (1860-1936) in miners (agog) and quarry workers (I gr 2) (Haldane agog, rgr 2) and the Commission on Miners’ Phthisis in South Africa (Miners’ Phthisis Prevention Committee 1913). After mechanization of mines the amount of dust increased. M. J. Stewart and J. S. Faulds (I 934) pointed out that haematite mining was safe until the introduction of the pneumatic drill in rgr 3. All these observations resulted in the introduction of laws defining the maximum amount of dust permissible in the air of the mines, and technical innovations in ventilation and dust suppression. While the use of asbestos in industry is modern, it is of interest to note that it has been known for over 2000 years, and Herodotus (450 B.C.) relates how the Romans mined it in Italy for enshrouding of corpses before cremation, so their ashes for burial could easily be collected. Pliny (A.D. 80) confirms the difficulty in working asbestos and refers to the use of respirators to avoid inhaling the dusts. Strabo (30 B.C.) and Plutarch (A.D. 70) refer to the wicks of the lamps of vestal virgins as ‘asbasta’, the unquenchable inextinguishable wick. Charlemagne had a tablecloth of asbestos which was cleaned by passing through fire. The first case of pulmonary asbestosis recorded in Great Britain was published by M. Murray in 1907; the patient died in Charing Cross Hospital with extensive pulmonary fibrosis. The relationship between asbestos and pulmonary
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fibrosis was established in 1928. This led to the report of E. R. A. Merewether and C. W. Price in 1980, and similar reports from Germany. Between 1930 and 1934 cases occurring at the Cape Asbestos factory were investigated by S. R. Gloyne (r882-1950) and W. Burton Wood (1884-1943) at the London Chest Hospital (Wood & Gloyne 1930) and D. Hunter at the London Hospital (Hunter I 955). Gloyne later pointed out the frequent association of pulmonary neoplasms with asbestos (Gloyne 195 I). These then are perhaps the most important stepping stones in the history of chest medicine up to the beginning of the modern era. ACKNOWLEDGEMENTS
The illustrations for this of Diseases of the Chest.
article
were
kindly
supplied
by Mr
Bishop,
Librarian
of the
Institute
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