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0 I_f. B. Rosenblat'r

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Abstract

During the first half of the i gth century, physicians in the United S~ates derived most of their infomaation on emphysema from European publications. In t845 a comprehensive review of the subject appeared in The Cyclopedia of Pr,rctic,rl Aledicine,~ published in Philadelphia. The author was Townsend, who made many contributions to the British literature. The article reviewed the development of knowledge of emphysema in Europe. Townsend accepted LaiSnncc's concepts of pathogenesis and acknowledged tl~e etiologic importance of bronchitis.

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Named Organization
Abbott Laboratories
American Board of Radiology
American Cancer Society
American College of Cardiology
American College of Chest Physicians
American Heart Association (Voluntary health organization that focuses on cardiac health)
Voluntary health organization that focuses on cardiac health and stroke. AHA occasionally teams with tobacco retailers to engage in promotions/fund-raisers (see http://www.smokefree.net/doc-alert/messages/247136.html and http://www.rawbw.com/~jpk/stand/Pictures.html).
American Medical Association (physicians group)
Professional trade group representing American physicians.
American Society for the Control of Cancer (Cancer control group)
Cancer control group
Archives (National Archives and Records Administration)
Argonne Cancer Research Hospital
Army
Associated Press (AP) (National Uniform Press Service)
Association for Cancer Research
British Medical Journal (BMJ) (scientific periodical)
scientific periodical
Brompton Hospital
Chapel Hill
Charity Hospital (New Orleans)
City Hospital (California)
Committee on Agriculture
Consumers Union (Publish Consumer Reports)
Cornell University (Ithaca, New York)
Doctors Hospital (Coral Gables)
Federal Trade Commission (Enforcement agency for laws against deceptive advertising)
Enforces laws against false and deceptive advertising, including ads for tobacco products. Ensures proper display of health warnings in ads and on tobacco products;collects and reports to Congress information concerning cigarette and smokeless tobacco advertising, sales expenditures, and the tar, nicotine, and carbon monoxide content of cigarettes.
FYI (Philip Morris report of news clips circulated in NY)
Geriatrics (scientific periodical)
House of Representatives
Industry Research Committee
International Brotherhood of Teamsters (IBT)
Jackson Memorial Laboratory
Jefferson Medical College
Johns Hopkins University
Kellogg (Cereal Company)
Lancet
Louisiana State University
Mayo Clinic (Located in Rochester, Minnesota)
Has a nicotine dependence center; runs the smoking cessation program at the Mayo Clinic
McGill University (Prestigious Montreal university which cooperated with the in)
Helped the tobacco industry obscure the link between secondhand smoke exposure and illness
Medical College of South Carolina
Medical World News (scientific periodical)
Merrill Lynch
Metropolitan Life Insurance (Insurance Company)
Mount Zion Hospital
National Library of Medicine
Navy
New Scientist (scientific periodical)
New York Academy of Medicine
New York Medical College
New York Times
New York University
Newsweek (Weekly News Magazine (U.S.A.))
Ohio State University
Oxford University
P. Lorillard Company
R.J. Reynolds Corporation (second tier subsidiary of RJR Industries)
*Scientific Advisory Board (SAB) (Only use SAB with name of specific org.)
Scripps-Howard
Senate
Simmons Market Research Bureau (Advertising auditing company)
Southern Medical Journal (periodical)
Tobacco Industry Research Committee (TIRC) (Renamed Council for Tobacco Research-USA (CTR))
Organized in 1954 as the Tobacco Industry Research Committee (TIRC), and renamed the Council for Tobacco Research-USA (CTR) in 1964.
Tobacco Institute (Industry Trade Association)
The purpose of the Institute was to defeat legislation unfavorable to the industry, put a positive spin on the tobacco industry, bolster the industry's credibility with legislators and the public, and help maintain the controversy over "the primary issue" (the health issue).
Union Carbide
United Hospitals
United Press International
United States Public Health Service (Headed by the Surgeon General)
United States Public Health Service is headed by Surgeon General of the United States.
University of Arkansas
University of Chicago
University of Illinois (at Champaign-Urbana)
University of Michigan
University of Oregon
University of Southern California
University of Texas
University of Wisconsin
US Army
Veterans Administration
Washington Post (Newspaper)
Washington Star
Yale University
Named Person
Adler, Dr. Isaac (Early Physician who noted Lung Cancer as rare disease)
Plaintiff
Adler, Lou
Angeles, Les
Baptist, John
Barney, Leroy E.
Batten, James (CEO of Knight-Ridder newspapers)
Bennett, James
Berkson, Joseph, M.D. (CTR Special Projects, Biostatistician, Mayo Clinic)
Wrote articles and letter expressing doubt that there was any real connection between cigarette smoking and cancer.
Blatnik, John A. (Representative (D - Minnesota), subcommittee chairman)
Boyd, William
Bracket, Ed
Brown, Robert R.
Buford, Thomas H.
Burney, Leroy E., M.D. (U.S. Surgeon General 1957)
Dr. Leroy E. Burney was the United States Surgeon General under Eisenhower (1957) (E. Whelan 1984; Dallas MN 1/12/94).
Butch, Philip
Carey, Frank
Cleary, David M.
Cobb, Sidney
Collier, Robert
*Comroe, Julius H., Jr. (use Comroe, Julius Hiram Jr., M.D.) (CTR SAB, Grantee, Pulmonologist, U of CA, San Francisco)
Defense
Connelly, Bill
Connelly, William
Cook, Clarence
Cooke, William
Darnley, J. Dana
Dear, Joe
Plaintiff
Dec, Noah Mini
Dehart, Ed
Doll, Richard
Dorn, Harold F. (Chief Statistician for the NIH)
Duffin, Anne H.
File, Lucien T.
Flint, Austin
Floyd, John H.
Forbes, John
Greene, Harry S. N., M.D. (Pathologist, Yale U School of Med, Industry Expert)
Was quoted in Liggett & Myers' 1957 Annual Report as saying "The evidence...does not appear sufficiently significant to tme to warrant forsaking the pleasure of smoking."
Halprin, Kenneth M.
Hammond, E. Cuyler
Heidbreder, Gerald A.
Holmes, Oliver Wendell Jr. (supreme court justice)
Hubbard, Henry
Jackson, Roscoe B.
Jenner, William
Jew, Edward
Johnson, Albert C.
Kanner, Leo
Kirkman, Don
Klein, Russell C.
Kloepfer, William J., Jr. (TI Public Affairs VP, c. 1988)
Senior Vice President of Public Affairs Relations for the Tobacco Institute
Lew, Edward
Li, Clarence Cook
Lisa, James
Lisa, James R.
Little, Clarence Cook, Sc.D. (CTR Scientific Director, 1954-1971)
Loan, Van
Low, Edward
Luth, Martin
Macdonald, Ian (Clinical Professor of Surgery University of Southern Califor)
Marley, Faye
Maxwell, Jack (Securities Analyst, Oppenheimer)
Plaintiff
Mayo, Charles W.
Moss, Emma
Myler, Joe
Myler, Joseph
November, Sunday
Passey, Richard
Randal, Judith
Randal, Judy
Reiner, Anita
Rodgers, Joann
Ros, Milton B.
Rose, Milton B.
Rosenblatt, Hilton
Rosenblatt, Milton
Rosenblatt, Milton B.
Rosenblatt, Milton E.
Rosenblatt, Milton R.
Ruddock, John
Seal, John
Shaw, Robert
Steiner, Paul E.
Stocks, Percy
Stokes, William
Stone, Marvin
Stuart, Kenneth
Sutton, John Bland
Sweet, Richard H.
Thompson, Carl G. (Hill & Knowlton VP)
Hill & Knowlton Vice President.(PMI's Introduction to Privilege Log and Glossary of Names, Estate of Burl Butler v. PMI, et al, April 19, 1996)
Trinidad, Salvador
Underwood, Paul B.
Vaughan, Rupert
Watts, John C.
Webster, James
Western, Joseph
Wilhelm, John
William, Robert
Young, John D.
Zahn, Leonard S. (CTR Public Relations consultant)
Leonard Zahn & Associates, Public Relations consultant to the tobacco industry
Master ID
TI09781644-3113

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Page 1: TI09782932
~ ~ 0 i~f. B. ROSENBLAT'r During the first half of the i gth century, physicians in the United S~ates derived most of their infomaation on emphysema from European publications. In t845 a comprehensive review of the subject appeared in The Cyclopedia of Pr,rctic,rl Aledicine,~ published in Philadelphia. The author was Townsend, who made many contributions to the British literature. The article reviewed the development of knowledge of em- physema in Europe. Townsend accepted LaiSnncc's concepts of patho- genesis and acknowledged tl~e etiologic importance of bronchitis. The clinical features, diagnostic physical signs, and anatomic findings were described meticulously, enabling American physicians to gain an im- proved understanding of the disease. The hazards of recurring attacks of bronchitis in perpetuating the severity of emphysema were also stressed. Some interesting observations on the pathology of emphysema were made by Hasse'~ in his book on circulatory and respiratory diseases (z846). The author acki~owledgcd the French and English contribu- tions and accepted the relation between bronchitis and emphysema but added that the disease might have other causes. He referred to Louis's study of 53 cholera patients, z 3 of whom were found at autopsy to have chronic emphysema. Fie also mentioned cases of tuberculosis in which the adjacent'l~orti~ns, of the lung were emphyscmatous. Hasse was deeply impressed by the coexistence of emphysema in cases of fibrotie tuber- culosis; he postulated that emphysema presented a barrier to the spread... of tuberculosis and contributed to the cure of the disease. Hasse de- scribed the emphyscmatous lung most precisely. He noted the dry appearance, the lack of elasticity, the diminution of the capillary bed, the distention of air vesicles, and the rupture of blebs, which permitted air to escape interlobularly or into the pleural cavity. Although pulmonaD, diseases were recognized in antiquity, the func- tion of the lungs remained obscure for ahnost z,ooo years. The subject had intrigued philosophers and scientists but little basic knowledge was gained. The degree of confusion was epitomized by Samuel Pepys. After attending a meeting of Gresham College in which respiration was discussed, he wrote in his diary under the date of January 2z, ~665; % . . it is not to this day known, or concluded on among physicians, nor to be done either, how the action is managed by nature, or for what use it is." Of interest, but irrelevant, w;~ an adjacent entry stating that during the meeting one of the doctors defended the exodus of his fellow physic had dc In in nor almost tion w all SUli page t more this tc Was Hutcl more limitc~ article micro. chang alveol "WaS b and d the cl lungs. Dt cludc~ in Ph Swett morc descri tion brollc In lllCaS~. thora jCCt~S catoc the d Vd. 43. T109782932
Page 2: TI09782933
~e United European appeared iladelphia. :he British ge of era- of patho- hitis. The in~ were in an im- a¢~ attacks were also ema were diseases contribu- :sema but ~o Louis's :v to have in xvbich 'as deeply ".ic tuber- he spread -lasse de- the dry bed, the uitted air the func- :e subject :'dge was :1 Pepys. :tioli was : .., t665; ,)'slcians, /or what 'ing that lis fellow EI~IPII[YSEN~[A: HISTOItlC.~.L |~ERSPF~'IVE 83I physicians duriug the plague; lie explained that inasmuch as their patients had departed, there was little for the physicians to do. In ~667 Lower:~ demonstrated experimentally the processes involved in nomlal breathing but little atteution was given to these studies for almost ~oo years. The first outstanding publication on respiratory func- tion was made by Hutchinson~ in ~ 846; it provided the facts upon which all subsequent studies of pulmonary function have been based. The ~ 14- page thesis described the subdivision of puhnonary volume; although more than a century has passed, o.nly a few changes have been made in this terminology. Hutchinson's instrument for measuring vital capacity was called a spirometer. In order to insure accuracy in his measurements Hutchinson prepared tables based on the height, weight, and age of more than 2,ooo subjects. His studies on the diagnosis of disease were limited to tuberculosis but lie predicted a wider use of his instrument. In I848 the London Medical Gazette published two notexvorthy articles on emphysema. The first was by Rainey,~s who described the microscopic anatomy of the disease. Raincy notcd the destructive changes in the alveolar capillaries and the repla,c..cn.3.cn.t,of the distended alveolar walls by thin bands of fibrous ti~uc. The other contribution was by Sibsonfl~ who made extensive anatomic studies on hypertrophy and dilatation of the right ventricle resulting from emphysema and on the effects of displacement of the abdominal viscera by the distended lungs. During this period two American texts on diseases of the chest in- cluded informative chapters on emphysema. Gerhard's~° book, published in Philadelphia in ~85o, emphasized the clinical features of the disease. Swett's~ book, published in New York in ~85z, contributed a much more extensive discussiou of the pathologic features. It included detailed descriptions of the honeycombed lung, atrophic alveolar walls, destruc- tion of capillaries, and inflammatory lesions of the adjacent small bronchi. In ~ 850 Quaina'-' devised an instrument called the stethometcr, which measured respiratory excursions by means of a string placed arouud the thorax and attached in frout to a graduated dial. The depth of the sub- ject's respiratory movements was rc/lectcd in the rotation of an indi- cator on the dial. The instrument could also be used to compare the expansibility of the two halves of the chest. The inventor hoped that the device would help in the diagnosis of emphysema and other pul- V0L 48, [10. 6, lul~" 1972 TI09782933
Page 3: TI09782934
8 ~ Z ~,f. B. ROSER~BLATT monary disease but he was very well aware of the device's limitations. By t853 emphysema had attained sufficient prominence to become the subject of an international dispute. The chief protagonists were Gairdner,~3 a distinguished British clinician, and Gabriel Andral, the renowned French specialist in pulmonary diseases. Gairdner completely rejected LaEnnec's hypothesis that dilatatiou of the alveolar spaces re- sulted from inability to emit air through obstructed bronchi. Gairdner also discarded the opinion that degenerative changes in the alveolar xvalls contributed to the formatiou of large blobs. Instead, he believed that dilatation of the air vesicles was the mechanical result of inspiration in lungs which were partly collapsed or diseased. Gairdner's article, pub- lished in the Brieisb and Forei~,~t Medical Re'dew,, was refuted in the September r854 issue of the Archives g~m:r,des de mgdici~te by Andral, who not only denied the validity of Gairdner's beliefs but also accused him of plagiarizing from Gallard.~4 The irate Gairdner fumed for txvo days and then wrote a vitriolic letter~ to the editor of the Arcloives completely demolishing the concepts of those who took issue with him and documenting his claim to originality. One of the most impressive German contributions to the subject of emphysema during this period was included in a monograph on respira- tot3, disease.by.).V.i.ntfiehJ" which appeared in t854. The author investi- gated many aspects of pulmonary function and devised a spirometer which closely resembled the modern instrument except that the inner component consisted of a large glass bottle instead of the metal cylinder that is now in use. Like his predecessors, Wintrich hoped to gather su~cient data so that the measurements would have diagnostic signifi- cance in the detection of emphysema and other pulmonary diseases. In ,857 William Jenner~r published a knowledgeable article on the etio- logic aspects of emphysema. He stressed bronchitis as the primary cause and he contended that partial bronchial obstruction xvas followed by a chain of physiologic and pathologic processes wlfieh resulted in degen- erative changes in the pulmonary parenchyma. Jenner attributed the frequent occurrence of the disease in the upper lobes to the greater compressibility of the lower lobes in expiration. During the decade from ,86~ to ~87, many articles on emphysema appeared in the medical literature. Rokitansky~s and Skoda".3 included discussions of the subject in their classic texts. Schmidtlein;° and Men- jaud~* worked on the newer concepts of pathologic physiology. Ville- cc~ orr ma CO~ logl ," gat~ rdz¢ tcm mot dise: cerI~ emp ~eat~ ture OCC~ dise: origi the : Je logic was ~ and cervi the r TI09782934
Page 4: TI09782935
nitations. , become isrs were dral, the ,mpletely paces re- Gairdner ~lar ,.vails wed that iration in cle. pub- :d in the .- Andral. ) accused t for two Archives with him '_,bject of respira- :.' investi- ,irometer :i~e inner cylinder ,i gather ." signifi- ~:ases. In :he etio- ~rV cause • cd by a : dcgen- • ~rcd the greater :']~vscma ::tcluded .,1 Men- . Ville- HISTORICAL P ERSPECIT¢I~ 833 min~-~ described the histologic changes that occur in the alveolar spaces. Greenho~w~s presented a comprehensive picture of the pathogenesis of emphysema caused by bronchitis, differentiating it from senile emphy- sema. Hensley"~ contributed a detailed critique of the prcvailiug con- cepts of the development of emphysema and stressed their inadequacies. He concluded his essay with a comment: if progress seemed slow, it should be remembered that ~5o years previously John Floyer had rec- ommended that emphysema be treated by paracentesis of the thorax to permit the external air re "compress the flatulant tumor .... " An outstanding contribution to the pathology of emphysema was made by Lange,~ who differentiated further between the various types of enaphysema found at autopsy and clarified the pathogenesis of the compensator), and senile varieties. Lange's detailed descriptions of the cardiovascular complications of generalized ernphyscma reflect vast experience. Other writers of this period include 13iermcr"~ and Bayer,~r whose studies emphasized the interrelation between anatomic and physio- logic factors in the cmphyscmatous hmg, and Isaakssohn,'~s ~vho investi- gated the interalvcolar capillaries by dyc-injection.tcchnktues. In ~87~ a chapter on emphysema appeared iu Reynolds' System o~ Medich~e. The author was ~,Villiam Jenner,~° who was by then a recog- nized authority on the subject and was quoted widely by his con- temporaries. The introduction contains the following sentence: "Pul- monary Vesicular Emphysema is a very cotnmon, aud frequently a grave disease." Jenner made short shrift of the prevailing misconceptions con- cerning emphysema. He accepted LaEnnec's anatomic classification but emphasized that interlobular emplaysema, despite its dramatic clinical features, was relatively unimportant and merely resulted from the rup- ture of a bleb. He stated clcarly that subcutaneous emphysema could occur from trauma to a normal lung as well as from chronic pulmonary disease but the pathogenesis was entirely different. I-Ic also clari/icd the origins of the cn~physema which occurs in chronic tuberculosis and in the acute respiratozT diseases of children. Jenner's chapter was most comprehensive, covering an.atomic, physio- logic, and clinical aspects. The description of the cmphyscmatous patient was graphic: "The thorax is barrel shaped; the autcro-posterior, lateral, and vertical diameters are increased; the stcrnnm is arched; the lower cervical, dorsal, and upper lumbar spine is curved, concavity forward; the ribs are too horizoutal; the intercostal spaces are widened ... the 'v'0l. 4/3, ~to. 6,, My 1972 TI09782935
Page 5: TI09782936
costal angle is larger than in health .... The shoulders are raised .... " The description went on to include every aspect of physlcal abnor- mality. Great attention was given to cardiovascular and other complica- tions. Interestingly, Jenner stated that amyloidosis occurring in the course of emphysema was due not to the distention of tlae air vesicles but to concomitant suppurative bronchial infection. Jenner ridiculed the current m~dical and physical treatments; he stated that to be successful it would be necessary to renew the elasticity of. the alveolar walls, restore ~he structures to normal size, repair the apertures in the alveolar walls, and replace the destroyed capillaries. His advice was that bronchitis, the primary disease, be prevented by self- protection against the damp, cold, windy, and foggy English climate. The extensive work on spiromctry by Hutchinson and ~,Vintrich, previously mentioned, inspired the invention of a variety of instruments designed to measure ventilatory function. Most of these devices were soon discarded but two of them were popular for a long time. One was ~he pneumatometer, introduced by Waldenburg~° in ]87~ for the pur- pose of determining insplratory and expiratory pressure. The other was the Doppelsteth%raph, invented by Riegel"t in ~873. This machine recorded respirator), curves and demonstrated the prolongation of ex- piratio.n in emphysema. The basic idea has survived and is now used in spirome~ers-equlpped with timing mechanisms which record the forced expiratory volume. The first large statistical study of emphysema was published by Lebert~ in ~874. The material was derived from respiratory disease clinics in Breslau and Zurich and covered the period ~857 to t874. Of 6,458 cases with respiratory disease in Breslau, there were 764 cases (~z%) with emphysema. The proportion of males to females was 9:4- There were 950 sufferers from respiratory disease in the Zurich clinics; 96 (~o%) had emphysema, the proportion of males to females being 3: z. The total number of emphysema cases in the survey was 860. The author also quoted data by Biermer showing an annual increase of hos- pitalized emphysema cases of ~ to z~; studies made in Prague by Willigk showing a 9-7~ increase in autopsy" incidence; and Frrster's statistics, collected in Wi.irzburg, which showed a ~-3% of emphysema in the period from ~85z to ]859, and a 6% incidence in the period from ~859 to ~863. Ia t876 Marehand~ contributed a review of emphysema which prt its mc ~v~ de ca I'o pr ni th se d! lu B st n t~ f t t i t S T109782936
Page 6: TI09782937
aised .... " ical abhor- = complica- ing in the air vesicles tments; he ae elasticity repair the illaries. His ed by self- climate. i Wintrich, mmruments ~.viccs were d'. Onc x, VaS or the pur- other was ais maclfine ,.tion of ex- :,';w used in the forced .~blished by .ory disease 'o ~874. Of • -" 764 cases ,cs was 9:4- :'ich clinics; 'q being • 860. The • .'use of hos- Prague by i~j Fiirster's :'mphysema :,:riod from which EMP|IYSE.XfA: H1STORIt~.L PERSPECTIVE. 835 produced more confusion than enlightenment but was noteworthy for its bibliography of more than ~oo references. Birch-Hirschfeld's~ article (t877) in his textbook on pathologic anatomy was informative. This author noted the increased recognition of the disease in Germany and correlated the clinical manifestations with the pathologic findings. Measurements of ventilatory capacity dominated the testing of pul- monary function for man), years. Kranse's~ studies were intensive but were concerned chiefly with alterations in vital capacity. In ~883 Pick~° described his experiences with a variety of instruments. Fie favored one called the Roth Polygraph, which recorded respiratory movements on a rotating cylinder and made it possible to demonstrate graphically the prolonged expiration characteristic of emphysema. The first significant work on true respiratory function was contributed by Geppert~ in ~884. His im, estigations of alveolar gas exchange demonstrated the sig- nificance of carbon dioxide retention in emphysema and its relation to respiratory failure. In ~89~ Berenstein~s shoxved how detenninations of the residual air in the lungs could be used as a diagnostic test for emphy- sema. The basic knowledge for all current testin,~ of mdmonar~- func- tion was virtually" completed by yon BascI¢9 ~x "~ Sg"~ ~when he intro- duced instrumcnts for measuring the clasticity, or compliance, of the lungs. Almost all progress in the knowledge of emphysema was made by British, French, and Gennan investigators. Although there xvere no ont- standing contributions from the United States there was a gener~il aware- ness of the disease, exemplified by the discourse on physical signs in Austin Flint'sr° manual of auscultation and percussion in ~88o. Flint referred to the uniformity of physical findings in a series of cases of emphysema and strewed the characteristic thoracic deformity, respira- tory movements, diminished breath sounds, and the percussion note, which Flint named vesiculotympanitic. A lecture by Delafield,~ pro- fessor of pathology and practice of medicine at the College of Physicians and Surgeons, appeared in the Philadelphia Medical Times in ~885. Emphysema was one of the subjects covered. The manner of presenta- tion presumed that the audience was fanfiliar with the disease. After cit- ing the history and physical findings, Delafield stated "The diagnosis in this case is, of course, very simple" and proceeded to discuss etiologic considerations and treatment. He also derided the current textbooks for simplifying the pathogenesis. Vel. 48, ~o. 6, July 1972 T109782937
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~ ~ ~ ~[. B. ROSE~BLA'r'r European investigations of the pathologic anatomy of emphysema continued throughout the ,gth century. In ,886 l<liisF" made a detailed study of the histology of the emphysematous hmg and described the varied cellular changes in the alveolar walls. GrawitzTM in ,89z made further studies of the bistdogy of emphysema; he noticed how much more readily the disease was being recognized at autopsy. Being a German, he gave credit to Virchow rather than to La~nnec for directing attention to emphysema. In ~893 AuldTM emphasized the fibrotic changes in the pulmonary parenchyma. He also described degenerative changes in the nerves of the lung which he thought might facilitate distention of the alveolar spaces. The latter observation xvas related to experiments by Brown- ~quardTM in which section of the vagi in animals produced distention of the lungs. In ~899 Hausemam,TM introduced a variety of staining techniques to demonstrate elastic tissue changes and the role of inter- eonmmnieating openings between alveolar spaces in the produetloa of emphysema. During the last decade of the tgth century many treatments for emphysema were popularized; some of these are still in vogue in modi- fied form. Tt.~e effects of recurrent attacks of bronchitis were well rec- ognized and tr~tients'were advised to live in warmer climates during the winter months or, at least, to avoid exposure to dampness, wind, pol- luted air, and drafts. Expectorants, especially potassim'~ iodide, were prescribed generously, and the benefits and dangers of morphine were well known. The established treatment of right heart failure was digi- talis, veneseetion, and restriction of fluids. Physical therapy played an important role in the treatment of ambu- latory patients. I lydrotherapy and compressed air baths in specially designed pneumatic cabinets were recommended highly by most au- thorities. The latter treatment was also combined with breathing into rarefied air. Simple respirator), compression exercises were introduced in ~873 by GerhardF~ and with the passing of time gradually became more complex. Breathing-chairs were devised which assisted expiration by means of broad straps that pressed against the lower portion of the thorax. Elastic corsets were also introduced to facilitate expiratory movements. Respirator), exercises were given nmeh consideration and were meticulously prescribed to be performed under medical super- vision. In ,893 HughesTM published a book on respiratory gymnastics for I~I]. N. YoA~d. ~o~d. the instru cities insi In ~8, which Io connecte into the ing air i~ recent Ill given b~ gas, wh[, T~vo develoV Fowler':' text den' diagnosi The in Nod" exhaust! from ct physioi ~uoros( subject of the mental merdy in the ~ that ".~ table t this w Hoffn compl It presef readil epide~ opini~ TI09782938
Page 8: TI09782939
9-sema etailed ed the made much cing a retting .ional'y Ivcolar ]rown- :cntion taining iuter- don of lt.q for modi- :u rec- in~ the d, pol- • were 2 were ambu- 'ccially :St" au- • g into .,duced Wcalne "iratlon -f the :: atory ":~ and ,~uper- ics for ENLPHYSER~[A: HISTORICAL PERSPEC'TIVE 837 the instruction of doctors and patients, In many of the larger European cities institutes were established for the treatment of respiratory dis- In x89o Steinhoffr° introduced a therapeutic device for emphysema which looked like an upright piano; within ~vas a pumping mechanism connected to a series of pipes which ultimately led to a tube inserted into the patient's mouth. The purpose was to assist respiration by forc- ing air into the lungs. This instrument was probably the precursor of recent machines for assisted or controlled respiration. Oxygen was also given by direct inhalation from cyliuders filled with the compressed gas, which was inhaled through a mask. Two treatises published at the dose of the ~gth century epitomize the development of emphysema. One was an authoritative chapter by Fowlers° in the book, Diseases of the Lungs, published in 1898. The text dealt with pathogenesis, etiology, pathology, clinical manifestations, diagnosis, prognosis, and treatment. The .other publication was a monograph of i r3 pages-by-r0, offmanns* in Nothnagel's E~cyclopedia of Practical Medicine. The article was au exhaustive study of emphysema and discussed every facet of the disease from etiology to treatment. The subjects covered included respiratory physiology, pulmonary function tests, gaseous exchange, and even fluoroscopic examination of the chest. The author's familiarity with the subject reflected wide experience. He did not hesitate to ridieute many of the popular treatments. He was also critical of some of the experi- mental investigations of emphysema which accomplished little and merely served as arguments against vivisection. Hoffmama was adamant in the opinion that emphysema was a disease secondary to bronchitis and that "A true primary emphysema existed only in theory." It is regret- table that his comprehensive stud), oinitted statistical considerations, but this was a failing-or virtue-of most *gth century writers. However Hoffmann mentioned that Charbet, in 1881, in a study of cardiovascular complications of emphysema, had reported on a series of .,58 eases. It is apparent from these writings aud others-~'-' not included in this presentation that emphysema was common in the 19th century and was readily diagnosed by both clinicians and pathok~gists. Iu recent decades epidenfiologists, on the basis of death certificatious, have advauced the opinion that the disease has only recently begun to increase in fre- quency. According to official govermnent statistics, only x~5 emphy- 7~I.48, t1~. 6, Jul2¢ 1972 T109782939
Page 9: TI09782940
sema deaths were reported in ~935 in the entire population of the United States. There was a gradual increase in succeeding years and an upsurge in t95o, when 3,~57 deaths from emphysema were reported. By ~965 the number had risen to 23,000 and authorities~,sl predicted that the number of emphysema deaths might double ever), five years, e~~9th I It is difficult to reconcile the prevalence of emphysema in th century with official statistics showing virtual nonexistence of the dis- ease in the early decades of the zoth century. The present review is not concerned with the reasous for.this disparity except to point out that the sudden apparent increase of emphysema in the United States may well be an arttifact produced by revision of the InternatioTtal Li~t o~ the Causer o[ De,ub in ty49 permitting emphysema, for the first time, to be accepted as a primary cause of death. Other factors involved may be the recent increase in availability of pulmonary-function laboratories and therapeutic facilities, the widespread publicity given to emphysema in scientific and popular publications, and the social sccuriry compensation for disability from emphysema-which now exceeds $Ioo,ooo,ooo an- nually. The extensive x gth century literature on emphysema refutes the concept that the disease is a newcomer. The futility of arguing with . history la~s long be.e.n.s.ecognized. I. Boner, T.: 8epulehretura, ~iw ~lmtomia pratt[ca. Geneva, Chou~t, 1679, Book 1, Section 1, Obs. 5.% 56, 5L 2. Ruysch, F.~ Obse~'a~io,um aaatom[co- chir~r#[cnram cen~ar~a. Amsterdam, B~m, 1691~ Obs. XIX~ 8. Floyer~ J.~ The Physician's Pull# Watch. London~ Xicholsolb 1710~ vol. ~. 4. Floyer, J.~ d Treatis~ o[ the ~d ed. London~ Wilkin, 1717~ pp. 5. Watson, W.~ An account of what peared on opening the body of ~thmatic person. Ph~¢os. Trans. 6. Morgagni, J.: Th~ ~e~ts atl~ Canse~ Al~ander, B, translator. Imndo,, lar, 1769, yd. 1, B~k II, ~tter XII, A~ieles 12, 13. 7. Van Swleten, G.: Commentaria in Her- manni B~rhaave aphor[smss. Lugdunl Ba~vorum, Luchtmans~ 3d ¢~ vol. 4, pp. 140-$5. 8. Blagden, R. B.: Case of emphysema brought on by severe labor pains. l'~ac~s O5.~. "2:~5-%8, 1792. 9. Kellie, G.: An account of the ccntcsis being performed in the thorax for the cure o~ an emphysema. M. Philos. Comment. (Philadelphia) 1:¢98- 501, 1793. I0. Taranget~ A.t Observation dhm physem~ de~ pomuon% Ree. pdrio~ ~oc. 11. Heherden, Wn Commentarlg~ on H~storg and Cure o~ D~aso. London~ Payne, Badham, C.: Ob~en,at~on~ o~ th~ ]lammatory Affections o[ the ~/em~rane o[ ~he Bro,ch£~. London, Callow, IS. Hall~day, A.: 05sedations os s~ma. London, Lon~mmn, 180L ~4. Balfour, W.: A ease of ruptu~ of the Bull. t|. Y.A~O. hm~s koucke, 16. Rots, ped;¢t. 13. 1~. Cl~luct Ph.rm. 18. 19. son & de ~1. Lat:naec tranxhd, ~. To~vnsc~ Lungs. MedicS: ~3. Houaai, 2T. Pied:*= physi,,l mort. 25. Alder~ emtgh. 26. Andr., 27. cllniq orgar Mdd. 28. Stok, vcsic on Vol. 48,/~: T109782940
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n of the United and an upsurge orted. By" x965 dieted that the a'na in the xgth nee of the dis- at review is not ,int out that the ;totes may" well rtal List of the first time, to be red may be the ,boratories and emphysema in ¢ compensation 00~OOO,OO0 an- -"ma refutes the i arguing with use of emphysema :re labor pains. M. :792,. .mnf: of the para- ,treed in the thorax m emphysema. M. :'ifiladelphia) l:498- ~'allon d'un e~n- ~ll. .; Disease. London, :,~tlons o;~ the In- ,,.* o,f the Mucous • ,ronchiae. London, • atlons on 13mph~. ,ran, 1807. of rupture of the EI'~tPHYSENf.A: HISTORICAL PERSPECTIVE 839 lungs in partnrltion. Ed~nb'ar.eh 3$sd. J. 7:174-7~ 181I. 15. Bresclmt: Emphys~me. In: Dictioana~r~ des ,c[wnces mddlcales. Paris, Pane- koucke, 1815, vol. 12, pp. 1-1~. 16. Rees, A.: Emphysema. In: Tho ped[a. Philadelphi% Bradford, 1818, yd. I~. 1~. Cl~uet, d.: De l'influence des efforts ~ur 1~ organes renffirm6s duns ¢avlt~ thoracique. No~v. J. 3led. Chlr. Pha~. ~:~09-7~, 1819. 18. Baillie, M.: Tho Morbid Z~mtom~ ~oms o[ [ha Most Important Par~s o] th~ Haman Body, 6th ed. London, Buhncr~ 1818, pp. 78-80. 19. La~nnce, lt. T.: De I'a~cultatlon m~di- ats, on trait~ du diagnostic des des poumon~ at du coeur. Paris, Bros- son & Chaud~, 1819. 20. Murat: Emphysbme. In: Dictlonnaire ds m~decbw. Paris, Bdcbct, .1823, vol. ¢, pp. ~95-~9. 21. La~nnee~ lt. T.: A Treatise on tho Dis- sases of ths Chesg, 4th ed, Forbes, translator. London, [~ngman, 183L ~. Townsend, R.: Emphysema of the Lungs. In: Cyclopedia o[ PracHcal Med~cb~a. London, Sherwood, 1~, vol. ~, pp. ~3-28. ~3. Bouillaud, J.: Emphys&ne des poumons, ~mphysbmc non tranmatiqne. In: Dic- t[onnairs de m?decine et d~ prorogues. Paris, Mdqulgnon-Marvis, Baillibre~ 1831, lame 7, pp. 121-13~. 26. PicdagncI: Rcchcrches anatnmiqncs et physiologiques sur t'cmphys~.me du pou- man. J. Physiol. 9:~0-9~, 1829. 25. Alderson, J.~ Pathology of hooping cough. Mcd-Cldr. Trans. I~:78-93, 1830. ~6. Andral, G.: M Tr~aH.~e o~ Pathological Anatomy, Townsend R. and West, W, translators. Ncv; York, Wood, 1832, pp. 324-~3. S~. Hourmann and Dcchambre: Rechcrclms ¢liniques pour servir ~ l'hlstoire des maladies des vleiIlards: maladies des organes de ]a respiration. Arch. 3h:d. 8:~05-27, 1~5. ~8. Stokes, W.: Re~earehes on l,a~nncc's vesicular emphysema wltb observations on paralysis of the intercostal umseles and diaphragm, considered as ~ new VoL 4g. t,~. 6, July 1972 saaree of diagnosis. Dgblh~ d. Meal. 29. Stnkcs, W.: A 7'reatiso o~ tile nos~ and Treatment of Diseases of the Uh~L Philadelphia, Waldie, 1~7, pp. 1 l~-13k 30. Carswell, It.: Pathological ~nalomy. ~ndon, ~ngman, I~. 31. I~uls, P.~ Researches on Emphysema of the Lungs, Stcwardson, T., transla- tor. In: Duuglison's ,4meHcan Library. Pldladelphia, ~Valdic, 18~, 491-552. 32. Budd, G.: Remarks on emphysema of the lungs. La~tcet 2:482-~, 1839-1~0. ~. Laurel, C. and Erieksson, S.: Electro- phoretic dl-globulin pattern of serum alpha, anti-trypsln deficiency. Sca~td. J. Ciin. L~b. lnvest. 15:132, 1963. 3L Townsend, ~.: Emphysem~ of the Lungs. In: The Cyclopedi~ of Practical Med~cb~e. Philadelphia, Le~ ~ Blanch- ard, 1~5, vol. 2, pp. 17-21. 35. ltasse, E. ~.: Mn ~natomical De.¢cHp- t[oa of the l)ise<~ses of the Org,mt Ci;~u~iioff" ~nd Respiration, S~'Mae, W. ~., translator• London, Sydenhant Sac., lSl6. 3(L l,ower, R.: An experhnent concerning manner of respiration. Philo,. Tran~., 3:~5, 1731. 3~. Hutchinson, J.: On the capacity of the hmgs, and on the respiratory functions. Med. Chit. Tr. ~9:137-252, 18¢6. 38. Ralney, G.= 0n the minute anatomy of the emphysematous hmff. Loudon M~d. Oaz. 7:73, 1818. 39. Sibson, F.: Size and situation of the internal organs in vesicular emphysenm and bronchitis. London Mtd. Oa=. 7: 406-11, 1848. ~. Gerhard, ~V. W.: The Dia[lno~i~, Pa- thology a~td Treatment of the D~se~.~es of the Chest, 3d. cd. Philadelphia, Bar- ington and HasweH, 1850. 41. Swett, J. A.: M TreaHsa on the Dis- eases o[ the ChesL New York, Apple- ton, 1~2. 42. Qnain, R.: The stethometer. Loadoa J. Mcd. 2:923-27, 43. Gairdner, W. T.: Reflect XI. Brit. For. M¢d. Roy. ~:452-7~, I853. • k Gallard, R.: M~nmirc sur l'cmphysbme T109782941

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