Thursday, December 19, 2013

1700 B.C.: Hebrew Bible influences medicine

The Bible only has a few vague descriptions of diseases, and none of these vagaries are regarding our disease asthma. However, the Bible does provide some knowledge of what life may have been like for asthmatics in ancient Egypt, Mesopotamia, and among the early Jewish Community (Israelites, Hebrews).

The Bible is believed to have been written in the 1000 years that preceded the birth of Christ (10, page 511), although the information obtained in it is believed to go back much farther. Some some experts have actually estimated the Biblical date for the beginning of time to be 4004 B.C., (see my post: "4004 B.C.: The beginning of Time?" to be published 8/7/14). Since the authors of the Bible were recording legends previously relayed across generations by word of mouth, the stories had to be pithy. For this reason, actual dates may forever remain a mystery.

Hebrew history is interesting because the people were nomads, meaning they had no home, or at least they were in search of a home. Where they came from and why they left remains a mystery, and this is true of many of the societies that made their way to Egypt and Mesopotamia. Because the Hebrews were nomads, they lived among, and therefore were influenced, by the various cultures they came into contact with. Among these cultures were those present in and around ancient Mesopotamia and ancient Egypt.

The Babylonians believed that all disease was punishment from the gods, and some speculate this is why the Jews/ Hebrews likewise believed that their God, the only God, was responsible for causing all diseases and healing all diseases. Through priests, who acted as mediators, the Hebrew God healed, or he allowed the prophets to heal. (5, page 28)

The Hebrew were held captive in Egypt for several centuries prior to the exodus around 1550 B.C., and they were also held captive in Babylon around 604 B.C. So there are various references to both the Mesopotamian and Egyptians medical beliefs, providing evidence that the early Jews were influenced by both.

Fielding Hudson Garrison, in his 1922 history of medicine, explains that:
In the Old Testament, disease is an expression of the wrath of God, to be removed only by moral reform, prayers and sacrifice; and it is God who confers both health and disease: 'I will put none of these diseases upon thee, which I have brought upon the Egyptians: for I am the Lord that healeth thee.' (7, page 57)(Exodus 15:26)
After God gave Moses the laws, the Lord said, "If you will obey me completely by doing what I consider right, and by keeping my commands, I will not punish you with any of the diseases that I brought on the Egyptians. I am the Lord, the one who heals you." (Exodus 15: 26)
The Bible also refers to the Babylonian method of diagnosing through hepatoscopy, or inspecting the liver of sacrificial animals. It is by this means they diagnose through divination or omens:
"For the king of Babylon stood at the Paring of the ways, at the head of the two ways to use divination: he made his arrows bright, he consulted with images, he looked in the liver." (Ezekiel 21:21)
There are many references to God's ability to cause sickness and to heal, such as is mentioned by Job:
"God bandages the wounds he makes; his hands hurt you, and his hands heal you." (Job 5: 18) 
Abraham, who was labeled as "Father of Israel" by Israel's God, and who set the Israelites off on a quest for the land of Canaan, the promised land, mentions it sometime around the 2nd century B.C.:
Because of what had happened to Sarah, Abraham's wife, the Lord had made it impossible for any woman in Abimelech's palace to have children.  So Abraham prayed for Abimelech, and God healed his wife and his slave girls, so that they could have children. (Genesis: 20:17)
The prophet Jeremiah, who lived in the later part of the 7th century B.C., mentions it:
"But I will heal this city and its people and restore them to health.  I will show them abundant peace and security.  I will make Judah and Israel prosperous, and I will rebuilt them as they were before.  I will purify them from the sins that they have committed against me, and I will forgive their sins and their rebellion.  Jerusalem will be a source of joy, honor, and pride to me; and every nation in the world will fear and tremble when they hear about the good things that I do for the people of Jerusalem and about the prosperity that I bring to the city." (Jeremiah 33: 6)
"I will make you well again; I will heal your wounds." (Jeremiah 30:17 
Moses, who lived around 1550 B.C., mentions it as he calls for the Lord to heal his wife Miriam:
So Moses cried out to the Lord, "O God, heal her!"  (Numbers 12:13) 
Isaiah, who lived in the 8th century B.C., believed that not only was Assyria a great threat to Judah, but so to was the sin of the people.  In the Book of Isaiah, the Lord said of the Israelites:
"I have seen how they acted, but I will heal them.  I will lead them and help them, and I will comfort those who mourn.  I offer peace to all, both near and far!  I will heal my people.  But evil men are like the restless sea, whose waves never stop rolling in, bringing filth adn muck.  There is no safety for sinners," says the Lord. (Isaiah 57:18-21)
The prophet Hosea, who lived sometime before the fall of Samaria in 721 B.C., mentions it:
The people say, "let's return to the Lord!  He has hurt us, but he will be sure to heal us; he has wounded us, but he will bandage our wounds, won't he? In two or three days he will revive us, and we will live in his presence.  Let us try to know the Lord.  He will come to us as surely as the day dawns , as surely as the spring rains fall upon the earth." ( Hosea 6:1-3)
According to Garrison priests were hygiene police, meaning that they made sure the people of Israel washed and purified their bodies in order to prevent the spread of disease.  Yet the priests, he says, did not act as physicians.  Instead, this task was left to the physician.  (7, page 57)

In the Bible the various references to magi, or physicians, or high priests are usually in reference to Egyptian or Babylonian healers  So there was definitely a crossover of the beliefs of the various ancient societies.

The Bible has perhaps the first recorded evidence that physicians existed in Egypt about 1,700  years before the birth of Christ.  When Jacob died, "Joseph commanded his servants, the physicians, to embalm him; and the physicians embalmed Israel, and forty days were fulfilled for him, for so are fulfilled the days of those that are embalmed." (1, page 26)(10, page 17)(7, page 57)(Genesis 50: 2)

Garrison explains that "the king Asa consulted physicians instead of the Lord and 'slept with his fathers' for his pains (II Chronicles 16: 12-13), or that if two men fight and one of them be injured to the extent of having to keep his bed, she or her 'shall pay for the loss of his time, and shall cause him to be thoroughly healed.(Exodus 21:19)" (7, page 57-58)

While the Bible makes no mention of asthma nor asthma remedies, although it does make perhaps the first reference to a narcotic: (9, page 9)
During wheat harvest, Reuben went out into the fields and found some mandrake plants, which he brought to his mother Leah. Rachel said to Leah, “Please give me some of your son’s mandrakes.”  But she said to her, “Wasn’t it enough that you took away my husband? Will you take my son’s mandrakes too?” (Genesis 30: 14-15)
Mandrakes are a member of the nightshade family (solanaceae) of plants that, when ingested, can make breathing easeir and cause a hallucinogenic effect, easing pain and suffering.  The sonanaceae family of plants will play a significant role later in our asthma history, although it's doubtful (althgough possible) this was used as a remedy for dyspnea in the Biblical age.Further reading:
  1. Renouard, Pierce Victor, "History of Medicine: From it's origin to the 19th century," 1856, Cincinnati, Moore, Wistach, Keys and Co., page 26, chapter 1, "Medicine of the Antique Nation."
  2. "Moses," Catholic Encyclopedia,, accessed 3/21/13
  3. Puschmann, Theodor, translated by Evan H. Hare, "A history of medical education from the most remote to the most recdent times," 1891, London, H.K. Lewis
  4. Dunglison, Robley, author, Richard James Dunglison, editor,  "History of Medicine from the earliest ages to the commencement of the nineteenth century," 1872, Philadelphia, Lindsay and Blakiston
  5. Baas, John Herman, "Outlines in the history of medicine and the medical profession," translated by H.F. Handerson, 1889, New York, J.H. Vail and Co.
  6. Wilder, Alexander, "History of Medicine: a brief outline of medical history and sects of physicians, from the earliest historic period; with an extended account of the new schools of the healing art in the nineteenth century, and especially a history of the american Eclectic practice of medicine, never before published," 1901, Maine, New England Eclectic Publishing, Co.
  7. Garrison, Fielding Hudson, "An introduction to the history of medicine, with medical chronology, suggestions for study, and bibliographic data," 3rd edition, 1922, Philadelphia and London, W.B. Saunders Company
  8. "The Assiatic Journal, for British adn foreign India, China and Australia," volume VIII, New Series, May-August, 1832, London, Parbury, Allen and Co.
  9. Bradford, Thomas Lindsley, "Quiz questions on the history of medicine: from the lectures of Thomas Lindsley Bradford," edited by Robert Ray Roth, 1898, Philadelphia, John Joseph McVey
  10. Prioreschi, Plinio, "A history of medicine: Primitive and ancient medicine," volume I, 1991, New York, The Edwin Mellen Press
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2.5 million years ago: When did the first asthmatic live?

When did the first asthmatic live?  Since there was no written language before 2700 B.C., there is no way of knowing for sure.  So we are left to using our imaginations.

Consider for a moment, if you will, that the first asthmatic walked the earth sometime during prehistory (before the birth of Christ):

Let's go back 2.5 million years.  Back then people (or whatever you choose to call them) had the ability to adapt to their surroundings, and they had the ability to make stone tools and use them to hunt and prepare food.  Due to the material used to make these tools -- which was stone, this period of human activity is referred to as the stone age.

Today the stone age is divided up into two categories: (1, page 14-15)  One can only imagine if people way back then suffered from asthma, and, if they did, how they were treated by their fellows, and what the treatment, if any, would have been.

They must have existed sometime during the Stone Age. Just for the sake of our understanding, I will give a brief summary of what is known about this era.

The Stone Age
Paleolithic (Old Stone Age): 2.5 million years ago to 10,000 years ago (more than one humanoid)
Lower (early) Ended 125,000 years ago
Homo Habilis: 1.4-2.3 million years ago
Homo Erectus: 1.8 million to 300,000 yrs ago
Homo Sapiens: 500,000 years ago
Homo Sapiens Sapiens: 300,000 years ago.  
Middle (Mousterian): Ended 32,000 years agoHomo Sapiens Neanderthalis:
(sub-species of homo sapiens)
230,000- 20,000 years ago
Modern Homo sapiens sapiens migrate out of Africa: 100,000 years ago
Homo Sapiens sapiens Cro Magnum: Early modern humans: Began around 45,000 B.C.
Upper (late): Ended 10,000 years agoModern Human in Europe: 30,000 B.C.

Dawn of medicine: 30,000 B.C. Basket weaving was performed.
Nesothelic or EpiPaleolithic (Middle Stone Age): 10,000-5,000 B.C. (only humans remain)
Beginning and ending dates vary based on geographyClimate changes force people to search for new food sources. Humans begin farming, and begin domesticating animals, such as pigs, dogs, sheep, goats. New tools are needed to make the adjustment. Man invented pottery, ropes, nets, mats, and clothing
Neolithic or Alluvial (New Stone Age): 5,000 to the bronze age (Only humans remain)
Fertile Crescent: Begins around 7000 B.C

Generally lasts until metal tools are widespread, so in some places the stone age occurs earlier than others. In America it does not end until the Spanish Invasion around 1700 A.D.
Agricultural revolution (neolithic revolution): People start making pottery, and potter's wheel invented. People make tools of polished stone. New tools like saws and files of bone and stone are made. More complex settlements are formed.

We might as well take this a step further:

Bronze Age
Near East: 3600 to 1200 B.C
Europe: 3750 to 600 B.C
China: Begins 1600 B.C.
Copper and its alloy bronze are used.
Writing invented around 2700 B.C.
Iron Age
Near East: 1300 to 1600
Europe: 1200 to 400
China: begins 600 B.C.
Iron or steal used for weapons and agriculture
Black smiths a common trade

Surely knowledge of asthma, or asthma-like diseases, was known during prehistory (before 2700 B.C.), although this knowledge was shared by word of mouth, and therefore most of it is probably lost to time.  Chances are likely that without the shared word, most generations had to start from scratch, making progress unlikely.

Some of this wisdom, however, was recorded about 2700 B.C. when a written language was invented.   Some of these documents have been found, and, therefore, it is from these we can gain a picture of what ancient civilizations knew about our disease.

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Saturday, December 14, 2013

History of Difficult Breathing

It's time we embark on a journey through the tunnels of time.  Yet rather than traveling along the warpath of mankind, we'll be traveling along the path of disease, particularly asthma and respiratory therapy.

Like the path of war, the path of disease takes us all the way back to the beginning.  Actually, certain diseases may go back farther than war itself, as they exist regardless of the desires of mankind.

This history begins the spring of 1981, although the tunnels will take us back to a time when the first people walked the earth.

I was dreaming I was unable to breathe. To use an overly used cliche, it felt as though an elephant was sitting on my chest.  No matter how hard I tried, and I tried vigorously, I could not get in half a breath.

Quickly I realized I was no longer suffering in a dream but real life.  I stood up on the bed and leaned against the window pane, putting my face up to the screen where a cool night breeze brushed upon my face, appearing to give me a slight hint of relief.

There was a little white Alupent inhaler clutched in my left fist, although there most of the medicine was gone except for a few drops.  I figured when I was absolutely desperate I'd run it under hot water and see if I could get one or two more puffs of relief.  But I had to wait just a little longer.

My heart was pounding from all the puffs I had already taken.  A fear within was that if I fell back asleep I might not wake up, but this fear arose from inhaler abuse more so than from difficulty breathing.  You see, I had nights like this so frequently during the first several years of my life I sort of just took it in stride.

It was this thought, of taking the inability to breathe in stride, that had me wondering about the past as I smelt the dusty screen.  I wondered how many people had suffered like this in the past, a time before medicines like Alupent existed.

What if I lived in 1881?  Worse, what if I lived in 1881 B.C.?  I decided that having asthma would have been much like this: suffering with no one to empathize with you because you didn't want to bother anyone.  Your parents and siblings were asleep, so you suffered alone.

I was introduced to the Alupent inhaler in 1980, I was ten-years-old.  I sat frogged up on the edge of the doctor's bed in Dr. Gunderson's office at the Apothecary shop on 1st Street in Manistee, Michigan. He told me to sit up high, take in a deep breath, and when I did he squirted the medicine into my mouth.  I inhaled as he instructed, holding my breath, regardless of the nasty taste, for ten seconds before I finally exhaled.

A minute later he gave me a second puff, and I took in a deep breath.  Ah, it felt so great to be able to breathe.

My mom held on to my Alupent inhaler for about a month or so, but she found that I asked for it so frequently she ended up just giving it to me.  I don't know if this was good or bad, because the medicine worked so well, and I was short of breath so often, I found I was using it without much hesitation.

Yet on this particular night as my inhaler had gone dry, the third time this had happened in the past month (Dr. Gunderson had said an inhaler should last about six months), I was hesitant to wake my parents because I had already bothered them too many times.

I certainly felt alone, yet not just alone in this room but in this world.  I had never seen anyone else suffer like this, nor heard of it.  So I was alone, the only person in the world stiff and struggling to inhale with his face against a window screen.

A few years later, in 1985, Dr. Gunderson and my parents would have me flown on a United Airline jet on a three hour trip to Denver Colorado so I could spend time with the best asthma doctors in the world at National Jewish Hospital/ National Asthma Center.  I would learn that I was not alone, that there were many asthmatics just like me.

Yet for the time being, I could feel my heart palpating fast and powerful, as I looked out into the dark night air trying to see if I could make the outline of a poplar tree, smelling the lilac bush just under the window, I wondered, just for a brief moment perhaps, if this was the fate of asthmatics prior to the discovery of modern medicine, and the invention of modern inhalers.

I did end up waking my mom up that night, and she was not angry as I suspected. Mom woke dad up and dad drove me to West Shore Hospital, where, despite my fear, no one inquired as to how frequently I had been using my rescue inhaler.  In fact, just the opposite as I expected, I was treated quite well.

A respiratory therapist started a breathing treatment, but, as expected, it was useless.  A nurse poked my right arm, and as she did so I watched the clock on the wall.  More specifically, I watched that second hand, and as soon as it spun around five times, just as I had experienced before, my breath came in like new.  I could breathe.

For a splint second, my mind wandered to a young boy, from 1881 B.C. perhaps, who was leaning against a tree to breathe sometime before the advent of modern medicine like Alupent and Susphrine.  Unlike me, he had no choice but to suffer alone and wait for nature to either give him his breath back, or give him peace through death.

While I didn't know it then, couldn't know it then, this was the beginning of my history of asthma and respiratory therapy.  A journey through time would take me all the way back the the beginning of mankind to the first person who suffered from asthma.

Yet asthma back then was more than just asthma, as people had no concept of changes in the body that resulted in symptoms.  So, back then, if you suffered from trouble breathing you were just having trouble breathing; your asthma-like symptom was your disease.

Surely I knew that I had asthma as we define it today, yet the boy from 1981 B.C. might just as easily have suffered from chronic bronchitis, emphysema, heart failure, influenza, tuberculosis, pneumonia, cystic fibrosis, scoliosis, osteoporosis, allergies, dyptheria, or kidney failure.  They were all diagnosed as the symptom of shortness of breath, or dyspnea, or as the ancient Greeks would later call it, asthma.

This is how it was for 99.9 percent of history.  As I enjoyed the relief provided by the shot, I couldn't help to appreciate that I was born in 1970, as compared with 1870, or worse, 1870 B.C.

Although, as we travel through time, we'll realize life wasn't much better for the asthmatic in 1870 as it was in 1870 B.C. Truth be told, there were few advancements in asthma medicine during this time.

So while most histories follow the path of war, the history of asthma and respiratory therapy follows the path of health and healing, with an emphasis on asthma, respiratory therapy, nebulizers and inhalers.  In order to organize this history I will use the following definitions:
  • Prehistory (prehistoric):  Time prior to the first written language, or recorded history, which is generally considered to be around 2700 B.C. 
  • Ancient:  Time after written language, or time with recorded history.  This period lasted from around 2700 B.C. until the fall of Rome in 476 A.D. 
  • Time:  After the birth of Christ people developed a need to keep track of time, and so the birth of Jesus was chosen as the date to begin time.  The date of his birth was estimated and this was chosen as 1 A.D. When a child is born we usually refer to the first year as zero.  With time the first 100 years is considered the first century, and therefore the years 100-199 were referred to as the 2nd century.  It's for this reason why the years 1900 to 1999 were referred to as the 20th century.  This is just how it is.  
This system was created to help people study history and keep track of dates and time.  Whether accurate or not, this is how history is recorded.  I will use this system to categorize this history of asthma:
  • Beginning to 5000 B.C.: Prehistoric people (prehistory)
  • 5000-2700 B.C.: Ancient Societies (Before History and Time)
  • 2700 B.C.-1 A.D.: Ancient Societies (During History, Before Time)
  • 1 A.D.-276 A.D.:  Ancient Societies (Beginning of Time)
  • 276 -1600 A.D.: Middle Ages (The Dark Ages of Medicine)
  • 1600-1800:  Age of Reason (The Age of Enlightenment)
  • 1800-1900:  The Scientific Revolution (the Age of Progress)
  • 1900-2000: The Age of Results
  • 21st Century:  The present
Considering the vastness of our history, and the brief time each person lived among it, this history is but a small glimpse of the past.  Most of our history is told by the select few privileged to learn to read and write, so it is nearly impossible to impress upon what life was like among the common folk.

Despite this, from the various pieces of literature left behind by those who suffered from this disease, or those who took care of those who suffered, we can gather a pretty good picture of what life would have been like for the asthmatic during nearly every era of human existence.  

So, what was it like to live with asthma in fill in location and year?  To best answer this question, I make a gallant effort to describe the various cultures. This, I think, should allow us to gain a more complete understanding of what it would be like to be sick if you lived among them.  

However, I would like you to consider the following quote from historian Henry E. Sigerist:
"We have no evidence whatsoever of any paleolithic medicine." (1, page 107)
I use this quote because there will be times throughout this history when we must use our imaginations to gain an understanding of what it was like to live with asthma in fill in the year and place.

So what was life like for asthmatics 2.5 million years ago?  Let's go!

(For the duration of this history, a post will be published every Friday and Saturday right here at the RT Cave.)

  1. Sigerist, Henry E "History of Medicine," volume I: Primitive and Archaic Medicine, 1951, New York, Oxford University Press
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Wednesday, December 11, 2013

460-370 B.C.: What did Hippocrates think about asthma?

Hippocrates is given credit as the author of the Corpus,
and therefore as the father of medicine.  The truth is,
however, that the figure in the bust here is probably
 a composite of what a typical physician would look like
around 400 B.C. The name Hippocrates has become
synonymous with the transformation of medicine that
occurred during this era of history.
As we peruse ancient writings we find many references to asthma, or at least asthma-like symptoms. The ancient Egyptians, Greeks, Chinese and even Japanese all recorded asthma-like events and the remedies to go along with them.  Yet it was Hippocrates,  particularly in his Corpus Hippocraticum, who made asthma a household name.

Please note here that Hippocrates was an actual physician, although his name is generally attributed to the medical wisdom of this era.  So as historians contribute the birth of medicine to Hippocrates, they are actually referring to the accumulated wisdom of Hippocrates and all of his immediate ancestors, fellow physicians, and immediate followers.

As far as we know, the first known person to use the term "asthma" was Homer in his epic poem the Iliad, which was written about 800 B.C. Homer used it to denote gasping or air hunger that occurred after physical exertion or during the process of dying.

As was typical of the era of philosophers in ancient Greece, Hippocrates had questions and he yearned for answers.  He wanted to know about all diseases, their causes and cures.  With limited ability to inspect the insides of the human body, his anatomical wisdom was limited.

He had no means of associating symptom seen outside the body with changes that occurred inside.  He therefore was forced to use reason to answer his questions about diseases such as epilepsy, dropsy, colds, catarrh, and asthma.  These answers were called theories.  They may seem quite spurious to the modern reader, although to the ancient Greeks they were quite logical.

So when Plato, and then Hippocrates, used the term asthma, they were pretty much denoting a symptom rather than a disease.  Plato used the term to denote short, gasping breaths by those wounded in battle or those who were exhausted after running from an enemy. Hippocrates used it in a similar way, although his definition was a bit more refined.

For example, Hippocrates defined the various forms of shortness of breath:
  1. Dyspnea: Shortness of breath
  2. Asthma (asthmata): Severe shortness of breath
  3. Orthopnea: So short of breath you have to sit up to breathe (a bad sign)
  4. Tachypnea: Rapid respiratory rate
In this way, he was the first to define asthma as a medical term. Since he didn't understand anatomy, asthma became a rubric term, an umbrella term, for severe breathing difficulty.  So from this point on, if you were short of breath, you had asthma, regardless of the natural cause.

To Hippocrates, then, like headache and fever, asthma was merely a symptom.

While this was a very vague definition, it was a start.  Later, as new wisdom was learned, the definition evolved.  Diseases that did not fit under the newer definition were extricated from under the umbrella term asthma to become disease entities of their own.

The first two examples were probably peripneumonia and phthisis, two diseases we now refer to as pneumonia and tuberculosis (consumption).  Diseases extricated after the death of Hippocrates were scoliosis, cardiac asthma (heart failure), kidney asthma (kidney failure), croup, chronic bronchitis, emphysema, and chest deformities.

It's interesting to note that chest deformities, such as diseases that caused curvature of the spine (scoliosis), were also considered asthma. This was true because such deformities resulted in less space in the chest for the lungs, leading to dyspnea. Hippocrates mentioned this in one of his Aphorisms:
Such persons as become hump-backed from asthma or cough before puberty, die. (17, page 141
Hippocrates also observed redness and inflammation inside the nose, mouth and eyes of some patients, and he referred to this as catarrh.  By this he was observing what modern physicians might diagnose as the common cold, bronchitis, or allergies.

He wrote a treaties "Of Epilepsy."  Prior to Hippocrates, epilepsy was referred to as the sacred disease because it originated from the anger of the gods, most likely Cybele, Neptune, Proserpine, Apollo, Mars, and Hecate.  Hippocrates tried to explain that epilepsy was "nothing more sacred or divine than an other." (11, pages 201-203)

Hippocrates believed that instead of being a divine disease, epilepsy had a natural cause, which started by an increase of phlegm in the brain that ultimately made its way to the veins and impeded flow of pneuma to the brain. He said:
This malady, then, affects phlegmatic people, but not bilious. It begins to be formed while the foetus is still in utero. For the brain, like the other organs, is depurated and grows before birth. If, then, in this purgation it be properly and moderately depurated, and neither more nor less than what is proper be secreted from it, the head is thus in the most healthy condition. If the secretion (melting) from the whole brain be greater than natural, the person, when he grows up, will have his head diseased, and full of noises, and will neither be able to endure the sun nor cold. (14)
Hippocrates, like Greek physicians before him, believed asthma was epilepsy of the lungs.  He believed that air (with pneuma) was inhaled and flowed through the body by means of the veins.  It flowed to the heart and brain and other organs in order to keep them functioning.

Hippocrates said:
By these veins we draw in much breath, since they are the spiracles of our bodies inhaling air to themselves and distributing it to the rest of the body, and to the smaller veins, and they and afterwards exhale it. For the breath cannot be stationary, but it passes upward and downward, for if stopped and intercepted, the part where it is stopped becomes powerless. In proof of this, when, in sitting or lying, the small veins are compressed, so that the breath from the larger vein does not pass into them, the part is immediately seized with numbness; and it is so likewise with regard to the other veins. (19)
He also believed that the humor phlegm was made in the brain.  When it was in excess it could flow to the heart and lungs, thus causing asthma. (9, page 61-62) (10, pages 14-15)

He said:
But should the defluxion (flow of humors) make its way to the heart, the person is seized with palpitation and asthma, the chest becomes diseased, and some also have curvature of the spine. For when a defluxion of cold phlegm takes place on the lungs and heart, the blood is chilled, and the veins, being violently chilled, palpitate in the lungs and heart, and the heart palpitates, so that from this necessity asthma and orthopnoea supervene. For it does not receive the spirits as much breath as he needs until the defluxion of phlegm be mastered, and being heated is distributed to the veins, then it ceases from its palpitation and difficulty of breathing, and this takes place as soon as it obtains an abundant supply; and this will be more slowly, provided the defluxion be more abundant, or if it be less, more quickly. And if the defluxions be more condensed, the epileptic attacks will be more frequent, but otherwise if it be rarer. Such are the symptoms when the defluxion is upon the lungs and heart; but if it be upon the bowels, the person is attacked with diarrhoea.  (14)
Mervyn J. Eadie and Peter F. Bladin, when writing about the sacred disease of Hippocrates, explained the thinking of Hippocrates regarding the cause of epilepsy and asthma.  They said:
He (Hippcrates or the Hippocratic writers) considered the disorder (epilepsy) in the following way:  during normal prenatal development the brain underwent a process of purification as it grew in the womb.  If this purification process did not occur, the sufferer was likely to grow up with a diseased head.  Purification of the brain might still occur after birth.  If so, phlegm would then be secreted into the upper respiratory tract or lost from the body in discharged from ulcers.  If such purification, which should have got rid of phlegm from the brain, did not occur at some state, the sufferer would be prone to experience epileptic seizures. When a 'defluction' of the retained phlegm from the brain occurred, the phlegm might go to the heart and chest to cause palpations, asthma, chest disorders and possibly spinal deformity. If it went to the abdoment it caused diarrhoea.  (18, page 94)
If the cold phlegm was not able to make it into the lungs or abdomen, it entered the veins where it obstructed the flow of pneuma.  When the pneuma was obstructed this could result in seizures, but it could also result in "interruption of inspiration."  (18, page 94)

When the pneuma was unable to make it back to the brain this caused "interruption of speech and intellectual functions, and loss of power in the hands.  The palpating veins affected the lungs to cause froth to emerge from the mouth.  The violent suffocation might cause involuntary defaecation, as the liver and stomach ascended to the diaphragm and the mouth of the stomach closed. (18, page 94)

So asthma was basically a symptom of a greater problem which ultimately originated from too much phlegm being created by the brain.

In his "Airs, Waters, and Places," he said:
...infants are subject to attacks of convulsions and asthma, which they consider to be connected with infancy, and hold to be a sacred disease (epilepsy). (14)
Hippocrates said:
Infants are subject to attacks of convulsions and asthma, which they consider to be connected with infancy, and hold to be a sacred disease (epilepsy) (13, pages 9, 11)
From these two passages many experts speculate Hippocrates observed that epilepsy and asthma were common in infants.

He also alluded to asthma as being "convulsive" or spasmotic in nature.  In other words, he alluded to what would later be referred to as the spasmotic theory of asthma, or that asthma was caused by "convulsions" or spasms in the lungs.

Paul Ryan, in his 1793 book "Observations on the history and cure of asthma," said:
It appears extremely probable that Hippocrates, in placing asthma... in contradistinction with pleurisy and peripneumony (pneumonia), must have had in view the spasmotic kind... he says that old men are very subject to difficult breathing, cough, and catarrhs and defluxion on the lungs. (9, pages 59-60)
After Hippocrates wrote about the disease as spasmotic in nature, later physicians suspected asthma was a nervous disorder.  It wouldn't be until the early 19th century that it was proved that Hippocrates was right all along, at least about asthma being spasmotic in nature.

Although others speculate that since asthma was associated with epilepsy, and that it was caused by defluxion of humors from the brain, that it was indeed a mental illness, or a nervous disorder.

Bernardino Ramazzini said Hippocrates was probably the first to describe asthma as a hazard of certain occupations.  Although the idea was scrapped until Ramazzini picked it up in the 17th century, and then scrapped again until the middle of the 20th century.

Hippocrates also accurately described asthma as a disease inherited along the family line, and while this was supported by an occasional physician along the historical timeline,  it wasn't proved until hundreds of years after the fall of Greece and Rome.

Despite his possible association of asthma with spasms in the lungs, he did not, as a general rule, associate diseases with specific organs.  This would be the accomplishment of a great physicians born into the 2nd century B.C. named Galen.

Hippocrates speculated that diseases were caused by certain changes in the winds, changes in temperature, or by the ingestion of certain foods. These caused a disunity within the body of the four qualities and humors, thus causing disease.

For example, some aphorisms describe asthma as occurring commonly in the middle ages, when the body functions start to slow down and cool, and in the fall season, when the temperatures start to cool.

Image of Hippocrates (12, title page)
Hippocrates said:
In autumn many maladies which occur in summer prevail, besides quartan and erratic fevers, affections of the spleen, dropsy, consumption, strangury, dysentery, sciatica, quinsey, asthma, volvulus, epilepsy, mania, and melancholy. (12, page 59)
He added:
To persons somewhat older, affections of the tonsils, incurvation of the spine at the vertebra next the occiput, asthma, calculus, round worms, ascarides, acrochordon, satyriasmus, struma, and other tubercles (phymata) but es- pecially the aforesaid. (16, page 134)
Ryan added:
...that the asthma mentioned by him was of the spasmotic kind, and that he considered cold and moisture its principle causes.  At least it must be allowed that this was his opinion with regard to the disorder in children. (10, page 62)
In review, he believed the following was true of asthma:
  • It was related to the epileptic resonse
  • It was hereditary
  • It was convulsive or spasmotic in nature
  • It was caused by an abundance of cold phlegm flowing from brain to lungs
  • It was common in infants
  • It was common in the elderly
  • It was caused by changes in seasons, such as from summer to fall (cooler air)
  • It was caused by some occupations
  • It is common in phlegmatic persons
It is generally believed that Hippocrates redefined the mode of assessing and diagnosing patients.  He made a thorough examination of the patient and his surroundings.  He assessed the patient's breathing both by observation with his eyes and with his ears.

He listened to his patient's breathing, took his respiratory rate, felt for a pulse, felt his skin for fever, observed perspiration and sweating, inspected his urine, inspected his sputum, among other things.

He may even have shook his patients in order to hear phlegm in the chest, a procedure called succussion (most often performed to diagnose empyema, or infection in the pleural space surrounding the lungs).

He would ask the patient questions:
  • Have you been around anything new lately?
  • Is there a history of this in your family?
  • Is anyone else sick in your family? In your city-state?
  • Has there been a change in winds recently?
  • What is your job?
If the patient was unable to answer these questions, he would ask friends and family members.  The answers to these questions would determine what changes occurred to the humors inside the patients body.  This would then determine the cause and the cure.

If the patient was diagnosed with asthma, the cures were the same as for any basic ailment, and were generally meant to assist nature in the healing process.  Such remedies included:
  • Bathing
  • Breathing purified air
  • Getting plenty of sleep
  • Eating a specific and healthy diet
  • Getting exercise
He also believed asthmatics should avoid whatever was thought to exacerbate it, and this may have been the best remedy of them all.  

If asthma did not improve with the basic remedies, only then would Hippocrates recommend other remedies, such as:
  • Massage
  • Glass of wine or Mandragora as a sedative
  • Draught of white hellabore to induce a good purging to cleanse the system. 
  • Bleeding (rarely)
  • Inhaling herbs
Asthma historian Mark Sanders said that another remedy he might have prescribed was inhaling the fumes of various herbs "boiled with venegar and oil" through a tube.  (7)

He provided medicine with the first viable description of asthma and the first simple remedies.  His remedies were mainly palliative in nature, offering the patient hope as he waited for the asthma episode to dissipate.

  1. Prioreschi, Plinio, "A history of medicine," vol II: Greek Medicine, chapter five, "Hippocrates," 2nd ed., 1996, NE, Horatius Press, 201-5
  2. Sigerist, Henry E "A History of Medicine," vol I, "Primitive and Archaic Medicine," 1951, New York, Oxford university Press
  3. Withington, Edward E, "Medical history from the earliest times: a popular history of the healing art," 1894, London, Aberdeen University Press
  4. Watson, John, "The Medical Profession in Ancient Times," 1856, New York,
  5. Fourgeaud, V.J, "Historical Sketches:  Galen," Pacific Medical and Surjical Journals, ed. Fourgeaud and J.F. Morse, Vol VII, San Franskisco, J Thompson and Co, 1864, page 22-29
  6. Meryon, Edward, "The History of Medicine," 1861, Chapter II, "The Greek System of Medicine, From the Time of Hippocrates to the Christian Era."
  7. Sanders, Mark, "Inhalation Therapy: An Historical Review," Primary Care Respiratory Journal, 2007, 16 (2), pages 71-81
  8. Cotto, Bob, "Who Discovered Asthma: Hippocrates or Galen?",, accessed 11/1/13
  9. Ryan, Michael, "Observations on the history and cure of the asthma:; in which the propriety of using the cold bath in that disorder is fully considered," 1793, London, Paternoster - Row
  10. Jackson, Mark, "Asthma: The Biography," 2009, London, Oxford University Press
  11. Hippocrates, "On Epilepsy," epitomised from the original Latin text by John Redman Coxe, 1846, "The Writings of Hippocrates and Galen," Philadelphia: Lindsay and Blakiston
  12. Hippocrates, "The aphorisms of Hippocrates," translated by Thomas Coar, 1822, London, Printed by A.J. Valpy, Red Lion Court, Fleet Street
  13. Hippocrates, "Airs, Waters and Places," translated by eminent scholars, 1881, London, Messrs Wyman and Sons 
  14. Hippocrates, "The Sacred Disease," translated by Robert Maynard Hutchins, "Great Books of the Western World: Hippocratic Writings on the Natural Faculties, 1952,; also see Hippocrates, "On the Sacred Disease," translated by Francis Adams
  15. Hippocrates, "Aphorism," section III, #22, translated by Robert Maynard Hutchins, " "Great Books of the Western World: Hippocratic Writings on the Natural Faculties, 1952, 
  16. Hippocrates, "Aphorism," section III, #26, translated by Robert Maynard Hutchins, " "Great Books of the Western World: Hippocratic Writings on the Natural Faculties, 1952, 
  17. Hippocrates, "Aphorism," section VI, #46, translated by Robert Maynard Hutchins, " "Great Books of the Western World: Hippocratic Writings on the Natural Faculties, 1952, 
  18. Eadie, Mervyn J., Peter F. Bladin, A disease once sacred: a history of the medical understanding of epilepsy," 2001, England, John Libby & Company Ltd.
  19. Hippocrates, "On the Sacred Disease," translated by Francis Adams

800 B.C: Homer was first to use the term asthma

Bust of Homer (British Museum, London). By using the term
asthma in his epic poem The Illiad, he became the first to
use the term in written literature.  
As a child Homer (800 or 850 B.C.) listened to poems recited by his dad about a war that occurred almost 400 years before he was born.  He was so impressed that as a young man he many spent hours in the open courtyard writing them down.

He couldn't remember word per word the stories his dad told.  What made it even more confusing was that his uncle sang the same stories, only the twists and turns were different. The names used, the plot, the ending, and the morals learned, however, were the same no matter who told the story.

So as he was jotting down the stories from memory, he realized it was okay to exaggerate and to expound at times in order to make his story more complete.  The important thing was to have the story in writing so future fathers could tell the same story every time it was told.  

As the years passed Homer became so rapt in his task that he became the slightly obese middle-aged, bearded man that is represented in the various busts of him. He would go down in history as one of the first and greatest story tellers of all time.

Whether or not he was actually the first to tell these stories may never be known, although what is known is he is often given credit.  This was because, unlike the ancient Egyptians and Mediterraneans, the ancient Greeks liked to associate works of writing to either the author or some famous person.  While Homer may not have been the creator of the Iliad, since he wrote it down he is given credit by history as the author.  (1, page 19-20)

It was a story of a siege at Troy estimated to have occurred between 1194-1184 B.C. (4, page 46)  After writing this story, Homer would write many more.  As eluded to above, he probably obtained most of his stories from those told by his ancestors by word of mouth, mainly through poems and songs that were easy to remember.  (1, pages 19-20)

Another thing Homer did, as his father and uncle did earlier, was add into the story modern events.  This made the story more interesting to the modern audience. While he may not have known it at the time, this would give future historians a better idea of what life was like in ancient Greece.  (1, page 19-20)

The story would also become significant to medical historians, because Homer made allusions to the state of medicine at the time.  While he described the battles, he also described battle wounds, and the symptoms that resulted from these wounds, sometimes in the process of dying.  So various medical historians have made reference to these allusions as some of the earliest knowledge of medicine. (1, page 19-20)

Homer was also the first, or so it is thought, to use the term asthma (άσθμα) in an actual piece of literature. (2, pages 10-11)

The term asthma is referenced in the Iliad, book XV, line 10:
"He saw Hector lying on the plain, his companions
sitting round him. Hector was gagging painfully,
dazed and vomiting blood." 
In this scene Zeus wakes up as the Greeks are trying to push a line of Trojans back, and he finds the Trojan leader Hector breathing painfully and vomiting blood. The above is the English translation, although the word Homer used for "gagging painfully" was asthma or asthmati.

Homer later made another reference to asthma in the Iliad, book XV, line 290:
"He was just starting to recover,
to recognize his comrades round him. He'd stopped
gasping and sweating, for aegis-bearing Zeushad revived his mind"
In this scene Homer described Hector as just starting to catch his breath.

Homer used the term asthma to refer to being winded as from fighting in battle, or as from wounds obtained in battle.  It made sense to use the term asthma this way, because it was a term meaning short, gasping breaths.  It was a vague term used simply to describe the symptom of dyspnea, or shortness of breath, regardless of t cause.

Another term that was sometimes used by the Greeks was panos, which meant panting.  Homer apparently preferred the term asthma.

Another early description of asthma was the sacred disease.  Actually, epilepsy was the sacred disease because the seizures were thought to be caused by divine intervention.  Those with the disease were thought to be rewarded with happiness in the next world.

Asthma was also referred to as the sacred disease simply because it was thought to be epilepsy of the lungs.  Perhaps the gasping efforts of the asthmatic made the chest appear as though it were seizing.  So if you had asthma you were blessed with eternal happiness.

While asthma was considered a divine blessing, this does not mean that the gods didn't cause all other diseases too, because they did.  This is confirmed, perhaps, by homer in his Odyssey (ix. 411):
 "the blinded and howling Cyclops is told by his friend that, if he is ill, he should remember that sickness comes from Zeus and is unavoidable." (3, page 38)  
Homer did not, however, refer to the disease asthma. His use of the term was simply to describe the symptom of dyspnea.

  1. Sigerist, Henry E, "A History of Medicine," Volume II, 1961, Oxford University Press, New York, pages 19-20
  2. Jackson, Mark, "Asthma: The Biography," 2009, Oxford University Press, pages 10-11.  Note:  While Mark Jackson is not the only person to acknowledge the Iliad as the first reference to the term asthma, I still want to give him credit here.  
  3. Withington, Edward, "Medical History from the earliest times," 1894, London, page 38
  4. Buck, Albert Henry, Williams Memorial Public Funds, "The growth of medicine from the earliest times to about 1800," 1917, London, Oxford University Press

Wednesday, December 4, 2013

1700-1940: "The asthmatic pants into old age."

There is a stunning array of evidence that prior to the 1950s, and even into the 1980s, physicians had a view of asthma as a benign disease; that morbidity (severity) and mortality (the death rate) from asthma was negligible.  The evidence comes in the form of quotes from the physicians themselves.

Dr. William Cullen (1710-1790), who wrote extensively on asthma, said:
"The asthma, though often threatening immediate death, seldom occasions it; and many persons have long lived under this disease. In many cases, however, it does prove fatal; sometimes very quickly, and perhaps always at length." (6, page 451)
Dr. William Withering (1741-1799), who recommended the diuretic digitalis for asthma, said:
  "The disease does not cut short the usual period of life." (4)
Dr. Rene Laenec(1781-1826) , the inventor of the stethoscope, said:
Asthma gives the patient the best hope of a long life. (9)
An attack of purely nervous asthma is rarely fatal. (17, page 443
Dr. Armand Trousseau (1801-1867)said:
Asthma was "the certificate of a long life."  (9) 
Dr. Francis Hopkins Ramadge, in his 1835 book "Asthma, its species and complications," said:
The prognosis of asthma is seldom difficult.  Doubt can arise only in cases severely complicated. When asthma wears the purely nervous form, danger is rarely to be apprehended." (18, page 36)
 Dr. Henry Hyde Salter, in his 1882 book "On Asthma: It's Pathology and Treatment, said:
"Asthma never kills; at least I have never seen a case in which a paroxysm proved fatal." 
(2, page 82)
Salter also said this:
"If death did take place from asthma it would by by slow asphyxia -- by circulation of imperfectly decarbonized blood; and before this occurred I think the spasm would yield."
Dr. J.B. Berkart, in his 1878 book "On Asthma: It's Pathology and Treatment," said:
"The prognosis of life is generally favorable.. the patient lives to the age of seventy and beyond, in spite of the intercurrent attacks of dyspnea." (10, pages 204-205)
Dr. John Thorowgood, in his 1878 book "Notes on Asthma," said:
During the intervals between his attacks the patient probably enjoys fair health, and, as a rule, lives to a good age; should he, however, be cut off prematurely by death; should he, however, be cut off prematurely by death, what do we find as the morbid anatomy to explain the wel marked symptoms seen during life? (16, page 2)  
Thorowgood also notes the following:
The prognosis in asthma is generally good, and asthmatics are well known to be, as a rule, long-lived; so that invalids who may have been for some time suffering in the chest are wont to feel much satisfaction and comfort when they are assured that their complaint is " only asthma," or is likely to " turn into asthma."  (16, page 35)
Dr. William Aitken, in his book "The Science and Practice of Medicine, said:
"Asthmatic patients generally live to a good old age." (5, page 489)
Osler also wrote in his 1892 medical textbook "The Principles and Practice of Medicine:
"We have no knowledge of the morbid anatomy of true asthma.  Death during the attack is unknown." (8, page 4)
Dr. Anthony Rebuck and Dr. Kenneth R. Chapman said in 1987:
It is now general knowledge that asthma can be fatal and that in some countries with a sophisticated level of medical care the death rates appear to have been increasing. Yet as recently as 1983 an editorialist in the Lancet found it necessary to point out that some physicians still considered the disease "a benign nuisance related mainly to emotional problems" (14, page 353
Dr. William Osler (1849-1919), the father of modern medicine, said in 1901:
 "The asthmatic pants into old age." (4)(7, page 3 and 11)
Dr. Lawrence K. Altman, in the 1990s, said the following:
In 1963, Dr. H.L. Alexander of St. Louis concluded that, prior to 1930, "death during an asthmatic attack was almost unknown." 
Altman also said:
"It (this belief) persisted well into this century.  A textbook in 1935, for example, said that the life of an asthmatic is not endangered. (8, page 4)
  1. Garrison, Fielding Hudson, "Introduciton to the history of medicine," 1922, London, W.B. Saunders Company
  2. Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment," 1882, New York, William Wood and Company
  3. Brenner, Barry, editor, "Emergency Medicine," 1999, New York, Marcel Dekker;  Brenner writes in his forward that "Osler though asthma never caused mortality." 
  4. Christennsen, Alan, Michael Antoni, editors, "Chronic Physical Disorders: Behavioral Medicine's Perspective," 2002, United Kingdom, Blackwell Publishers LTD., page 247
  5.  Aitken, William, "The science and practice of medicine," volume II, 1872, Philadelphia, Lindsay and Blakiston
  6. Cullen, William, "The works of William Cullen, M.D.," Volume II, London, 1827 (also see his book "First Lines of the Practice of the Phsych," 1784, Edinburgh, Vol. 3, 4th ed., page 399)
  7. Altman, Lawrence K., "The Public Perception of Asthma," Chapter one of the book "Fatal Asthma," edited by Albert L. Sheffer, New York, Marcel Dekker, Inc, pages 3 and 11. Lawrence notes the following about this quotation by Osler: "The origin of this statement is obscure.  Many authors have said it was one of Osler's aphorisms.  However, it is not included in the book of aphorisms." Other notable authors credit the following: William Henry Osler, "Principles and Practice of Medicine," 4th ed, 1901, Pentland, Edinburgh,
  8. Altman, ibid, page 4. Lawrence notes the following reference: "Osler W. The Principles and Practice of Medicine. Edinburgh: Petland, 1892
  9. Quoted in a variety of sources
  10. Berkart, J.B., "On Asthma: It's Pathology and Treatment," 1878, London, J&A Churchill
  11. Altmon, op cit, page 4.  The reference Altmon is referring to comes from an article by Speizer and Doll (see reference 12 below)
  12. Speizer, F.E., R. Doll, "A Century of Asthma Deaths in Young People,British Medical Journal, 1968, 3, 245-246
  13. Altman, ibid, page 2
  14. Rebuck, Anthony S. Kenneth R. Chapman, "Asthma: 1. Pathophysiologic features and evaluation of severity," Canadian Medical Association Journal, February 15, 1987, volume 136, pages 351-354.  The reference here referred to by the authors is "Childhood asthma", Lancet, September, 1983, volume 322, issue 8351, pages 659-660
  15. Speizer, F.E., R. Doll, P. Heaf, "Observations on recent increase in mortality from asthma," British Medical Journal, February 10, 1968, 1, pages 335-339
  16. Thorowgood, John Charles, "Notes on Asthma," 1878, 3rd edition, London, J and A Churchill
  17. Laennec, Rene Theophile Hyacinthe, "A treaties on the diseases of the chest, and on mediate auscultation," tranlated by John Forbes, 1838, New York, Philadelphia, Samuel S. and William Wood, Thomas Cowperthwaite and Company
  18. Ramadge, Francis Hopkins, "Asthma, its species and complications, or researches into pathology or disordered respiration; with remarks on the remedial treatment applicable to each variety; being a practical and theoretical review of this malady, considered in its simple form, and in connection with disease of the heart, catarrh, indigestion, etc." 1835, London,  Longman, Rees, Orme, Brown, Green, and Longman