400 B.C-1600 A.D..: Pneumonia defined as a disease

Hippocrates (460-377 B.C.)

Pneumonia was one of the few lung diseases to have an official diagnosis in medicine, as it was described as far back as 400 B.C. by Hippocrates. Pneumonia was a term to describe "a condition about the lungs."

We know, however, the condition was known prior to the ancient Greeks, as Hippocrates said it was "described by the ancients."

Surely ancient physicians as far back as 1250 B.C. in Egypt would have inspected the lungs of dead men wounded in battle, and observed that they were soft and spongy and pinkish in color.  Yet upon the rare inspection of a person who died of dyspnea, observed the lungs to be hard with a whitish discoloration.

Since the condition presented with obvious scars and obvious symptoms in life-- dyspnea, chest pain, body aches, fever, diaphoresis, coughing, colorful sputum -- it was one of only two lung diseases not to be lumped under the rubric term asthma by the ancient Greeks (the other being phthisis).

Pleurisy is a condition where the lining around the lungs becomes inflammed, thus causing chest pain.  He described the condition in his book "On the Different Parts of man."  He said:

We known an empyema (pus in a cavity of the body, particularly the pleural cavity) by these indications.  A patient at first feels a pain in the side, pus collects, and the pain continues with cough and expectoration of pus, and difficult respiration. If, however, the pus has not yet found an exit, concussion (succussion) of the body renders it perceptible in its fluctuation, by a similar sound to that of fluid shaken in a bottle.  (5, page 239)

In other words, Hippocrates believed pleurisy or empyema could be diagnosed by shaking a patient, which was a routine procedure performed by him when a patient presented with shortness of breath and chest pain.

He continued:

When these signs are absent, and yet empyema exists, it may be suspected from the great oppression and the hoarse voice; the feet and knees swell, principally on the affected side, the thorax curves, lassitude is extreme, universal sweats, alternating cold and hot, the nails become crooked, a sense of heat in the abdomen, all of which are so many indications of an empyema. (5, page 239)

While ancient physicians were sometimes able to differentiate pneumonia from asthma, they were not so gifted at separating chest pain caused by pneumonia from chest pain caused by pleurisy.  For this reason, the conditions were generally looped together as peripneumonia.  (1, page 192)

Of this, Hippocrates wrote:

"Peripneumonia, and pleuricic affections, are to be thus observed: If the fever be acute, and if there be pains on either side, or in both, and if expiration be if cough be present, and the sputa expectorated be of a blond or livid color, or likewise thin, frothy, and florid, or having any other character different from the common."

Hippocrates, in "The Different Parts of Man," section 1 chapter 1, and then again later in the book, said he believed diseases were caused by an imbalance of the four humors of blood, phlegm, black bile and yellow bile. Pneumonia resulted when the brain produced too much phlegm, and this phlegm overabundance of phlegm flowed to the soft tissues of the lungs.  While this might cause various pulmonary disorders, such as pneumonia, phthisis, pleurisy, cough, and thick sputum, he believed peripneumony resulted when both lungs were filled with the fluxation (flow, over abundance) of phlegms. Pleurisy results when one side is affected. (5, page 226, 228, 235, 238)(also see 5, page 268-270)

He believed pneumonia was the more severe of the two affections.  He said:

The pains are greater in the flancs and sides, the tongue is much paler, the throat suffers from the fluxion; the labour and oppression in respiration are extreme on the seventh or eighth day, death ensues from suffocation or weakness, or from both. If the fever, after diminishing for two days, returns on the ninth, death usually ensues, or else an internal suppuration has ensued; but if the fever is delayed, to the fourteenth day, the patient is safe. (5, page 238)

In "On Disease: Book III," he said that if peripneumony that if expectoration was sweetish by the eighteenth day, the lungs were in a state of suppuration (pus), and the condition would continue for a long time.  To diagnose suppuration, he recommended auscultation, which would have been done by placing an ear to the chest, as pus probably made a particular sound with each breath. Treatment for this was incision or cautery. (5, page 257, 260, 263, 266, 267)

The general treatment offered by Hippocrates for peripneumony would depend on the stage of the illness, age of the patient, color of the sputum, and season of the year.  Such remedies might include: (2, page 1)(3, page 481)

• Bleeding
• If fever, the bowels were opened with clysters
• If pain, hot water in a bottle or bladder, a sponge of hot water, or cataplasm of linseed was applied to the hypochondrium
• Linctus containing galbanum and pine fruit in Attic Honey or...
• Sothernwood in oxymel
• Oppaponax (a bitter resin with a garlic taste) mixed in oxymel
• Drink of ptisan made from huskey barley and mixed with oxymel  (2, page 1)(3, page 481)

For pleurisy, especially where pus has formed, Hippocrates recommended paracentesis of the thorax, which was a painful procedure that involved removing pus from the pleural cavity. (5, pages 260, 266)

Hippocrates described how to remedy pleurisy and pneumonia in "On the Different Parts of Man."  First he described how to cure pleurisy.  He said:

The cure of pleurisy is as follows. Do not endeavour to check the fever before the seventh day; prescribe either oxymel or oxycrat for drink, and give it copiously, in order to facilitate expectoration by dilution; heating remedies are to be used to calm the pains, and to favour a discharge from the lungs. On the fourth day the patient must be placed in the bath; on the fifth and sixth he is to be anointed with oil, and on the seventh the bath is to be renewed, unless the fever is diminished, and thereby excite perspiration. From the fifth to the eighth day the most active expectorants are to be employed, if the disease progresses favourably. Should the fever not decline on the seventh, it ought to do so on the ninth, unless some dangerous symptoms supervene. When the fever terminates, we employ the weakest broths; if diarrhoea ensues, the system being still vigorous, we omit the drink, and give barley water if the fever has ceased. (5, page 240)

Second, he described how to treat pneumonia.  He said:

Peripneumony is to be treated in the same manner. In case of empyema, mild errhines, to excite a discharge from the nose, and thereby relieving the head, are to be employed, and such food as will loosen the bowels; if the disease is thereby arrested, and the humours diminish, we are then to promote expectoration, both by medicine and by appropriate food, by means of which coughing is excited. In order to effect this, the food should be of a fatty and saline quality, with wine of a rough character. Phthisical patients are treated in the same way, with the exception of giving less food at a time, and wine more diluted, so that the debilitated system may not be too greatly heated, and an afflux of humours thereby induced. (5, page 240)

He did describe fumigations (5, page 241) and an inhaler of sorts, although he reserved these remedies for non respiratory ailments. For instance, when a woman does not feel her infant moving inside her uterus, one of the treatments for this was, among other things, fumigation (of smoke or steam). Fumigation was also a remedy for pituituos menstration.  It was also a remedy for severe ulcers, among other similar non-respiratory ailments.  (5, page 300)

The point of these therapies was to reduce the amount of phlegm in the body to return the humors to a homeostatic state.

Hippocrates was aware of when the disease was getting better or worse.  He was quoted here by Jock Murray: (2, page 2)

"When pneumonia is at its height, the case is beyond remedy if he is not purged, and it is bad if he has dyspnoea, and urine that is thin and acrid, and if sweats come out about the neck and head, for such sweats are bad, as proceeding from the suffocation, rales, and the violence of the disease which is obtaining the upper hand, unless there be a copious evacuation of thick urine, and the sputa be concocted; when either of these comes on spontaneously, that will carry off the disease."

Plutarch (46-120 A.D.)

Plutarch (46-120 A.D.) recognized that while pleurisy often accompanied pneumonia and may have been responsible for the pleuritic chest pain and fever, it sometimes occurred on its own.  He decided that the term peripneumonia was superfluous, and therefore referred to inflammation of the lungs as pneumnonia, and inflammation of the pleural sac as pleurisy. (2, page 2)( 1, page 191)

Hippocrates noted that death from pneumonia usually occured on the seventh day.  Areteaus of Cappadocia (about 140 A.D.) agreed with this.   He said, as quoted by Murray: (2, page 2)

"But if the lungs be affected, from a slight cause there is difficulty breathing, the patient lives miserably, and death is the issue, unless someone effects a cure. But in a general affection, such as inflammation, there is a sense of suffocation, loss of speech and breathing, and a speedy death. This is what we call peripneumonia, being an inflammation of the lungs, with acute fever, when they are attended with heaviness of the chest, freedom from pain, provided the lungs alone are inflamed."

The cures of Areteaus were similar to those of Hippocrates, although he adds: (6, page 2)(3, page 481)

• Wine (when fever subsides)
• Alkaline substances, such as soda, given in decoction of hysopp
• Rubafacients containing mustard applied to the chest
• Diluent drinks
• Purging (6, page 2)(3, page 481)

Other ancient physicians described pneumonia and its remedies in a similar fashion as Hippocrates, including Celsus (25 B.C.-50 A.D), and Galen (120-210 A.D.) and Aetius (396-454).  Still, it was Galen's remedies  that were were what were copied by most physicians for the next 1800 years, including the Arabic physicians. (6, page 2)(3, pages 481-482)

By the 7th century it was understood that pneumonia was inflammation in the lungs. Paulus of Aegineta described it this way:

Peripneumonia is an inflammation of the lungs, supervening, for the most part, upon violent catarrhs, cynanche, asthma, pleurisies, or other complaints, but being sometimes the original affection. It is accompanied with difficulty of breathing, an acute fever of the ardent type, weight and tightness of the chest, a rale (wheeze), a seizure of the face with great fulness, the morbific matter being determined upwards like fire. Wherefore the cheeks appear red, the eyes swelled, with falling down of the eyebrows, and the cornea appears somewhat glossy.

Aegineta listed the following as his remedies, all of which continue to be similar to those of Hippocrates: (3, pages 480-481)

• Clysters: Injected into the bowels, which are moved with difficulty
• Cupping:  Large cupping-instruments with scarifications may be frequently applied to the breast and sides, but only when there are no contraindications
• Bleeding:  If the peripneumonia was the original affection, and the strength permit, we must open a vein; or if not, we may cup, proportioning the evacuation of blood to the powers of the patient. 
• Drinks: Draughts of the juice of ptisan, or of chondrus with honey, be taken, or from bitter almonds with semilago, or chondrus having some sweet potion mixed with it, such as hydromel, apomel, or hydrorosatum. Fresh butter to the extent of three spoonfuls is also proper. The patient must also drink the propoma of the decoction of figs with hyssop, or of iris boiled in honied water, or of powdered iris, to the amount of two spoonfuls sprinkled upon honied water. This also evacuates downwards. To keep up the strength, he should be made to drink frequently of honied water alone, and with pine-nuts, and the seed of cucumbers. 
• Rubefacients: Cerate of the oil of rue and dried iris; or that made of wax, and rosin, marrow, butter, hyssop, dried iris, and nard ointment, may be applied to the whole chest and sides. 

Maimonides (1138-1204 AD) was the first physician to describe the signs of pneumonia similar to our modern description.  He said: (4, page 9)

"The basic symptoms which occur in pneumonia and which are never lacking are as follows: acute fever, sticking (pleuritic) pain in the side, short rapid breaths, serrated pulse and cough, mostly (associated) with sputum." (4, page 9)

So while pneumonia was recognized at an early date in history, not much was added to our wisdom regarding this disease, other than the sporadic opinions of the various physicians, until the last few decades of the 17th century.

References:

1. Allbutt, Clifford, ed, A System of Medicine, 1909, Toronto, chapter on "Lobar Pneumonia,"  by P.H. Pye-Smith, pages 191-205
2. Marrie, Thomas J, editor, "Community Acquired Pneumonia," 2002, New York, Kluwer Academic Publishers, chapter one by Jock Murray, "The Captain of Men and Death: The History of Pneumonia."
3. Aegineta, Paulus, "The Seven Books of Paulus Aegineta," translated by Francis Adams, volume I, 1844, The Snydenham Society
4. Rosner, Fred, "The Medical Legacy of Moses Maimonides," 1998, NJ, KTAV Publishing House
5. Coxe, John Redman, translator, "Hippocrates, the Writings of Hippocrates and Galen," 1846, http://oll.libertyfund.org/titles/1988, accessed 7/6/14, also see the book online at Google books, Philadelphia, Lindsay and Blakiston

400 B.C.: Hippocrates and the four humors

Humors are the fluids of the body, and Hippocrates, around 400 B.C., believed there were four humors: blood, phlegm (pituita), black bile and yellow bile. When these were in balance throughout the boy good health resulted.  Therefore, an imbalance resulted in disease.

The entire theme of Hippocratic medicine is based on creating a balance, or homeostasis (balance), of these four humors, or re-establishing a balance that has been broken.

The basic idea of the four humors is explained by Hippocrates in his book "On Disease: Book IV." He said that the humors are formed by the food or drink taken in.  There are five places in the body where humors are made: stomach, head, heart, spleen and galbladd.  Each of these organs "attracts is congenerous humour to itself." (1, page 269, 270, 271)

Phlegm comes from pituitous food and drinks, and is attracted to the head. When phlegm is in abundance it causes headache. (1, page 269)

In his book "On the Different Parts of Man," he explains that when too much phlegm is produced or attracted to the brain, so much so that the brain cannot contain it, the fluid flows down one of seven pathways to cause disease.  It could flow to the nose and cause catarrh and coryza.  It could flow to the lungs and cause pulmonary disease. It could flow to the spine and cause spinal tuberculosis, or Pott's disease.  (1, page 228-235)

Other pathways are the eyes and ears, where the various diseases of these organs are formed, including deafness an blindness. It could also flow to the muscles where it causes dropsy, the joins where it causes gout, sciatica and edema. (1, page 227)

He explains that yellow bile is produced by bilious food and drinks, and is attracted to the gallbladder. When "retarded" it results in pain. (1, page 269)

Black bile is also produced by bilious food and drinks, and is attracted to the spleen.  When in excess diseases such as melancholia and hypochondria may result. (1, page 269)

Blood is attracted to the heart, and its excess results in many diseases, such as dropsy, hydropsy, and fever.  (1, page 269)

A common way to resolve problems of excessive blood is to perform an operation with a blade called venesection or bleeding. However, Hippocrates rarely recommended the procedure.

Regardless of the what humor is in excess, a common way to re-establish homeostasis is by evacuating fluids from the body, such as in purging.  This allowed for any impurities to exit the system in order to cleanse the body.  There are essentially four pathways for this to occur: mouth, nose, rectum and urethra. (1, page 269, 271)

The way to produce purging, therefore, is to cause vomiting, expectoration, bowel movement, and urination.  Another method of evacuation was to cause diaphoresis, or sweating.

The best way to cause purging in cases where a disease is caused by excessive phlegm was to cause vomiting.  (1, page 282)

Causes of too much or too little of any of the humors was sometimes the result of the organ attracting too much to it, although most often it is the result of the food or drink consumed. Diseases may also arise from the air, atmosphere and season. They also arise from excessive temperatures:  too hot or too cold.   (1, page 226)(1, page 270, 271)

Hippocrates believed he best way to maintain homeostasis of the humors was to pay close attention to diet. He also recommended exercise and bathing.  He also recommended these in ill health, and only when these simple methods didn't work did he recommend other remedies, such as purging and bleeding.

References:

1. Coxe, John Redman, translator, "Hippocrates, the Writings of Hippocrates and Galen," 1846, http://oll.libertyfund.org/titles/1988, accessed 7/6/14, also see the book online at Google books, Philadelphia, Lindsay and Blakisto

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400 B.C. Tuberculosis is given a name

In the primitive world diseases were mainly described based on their symptoms. When the ancient Greeks observed that some patients appeared to be wasting away, they referred to their disease as phthisis, which means to consume or waste away.   Because it consumes, it would later called consumption.

While this is the disease we now refer to as tuberculosis, an ancient diagnosis of phthisis did not necessarily mean that the same patient would be diagnosed with tuberculosis today.  The truth is, while many patients diagnosed with phthisis might have had tuberculosis, they might have had any disease that can cause a person to seem to waste away, such as would be the case with many cancers.

So, as was the case with the term asthma, phthisis was essentially an umbrella, or rubric, term.  Phthisis referred to any condition that caused a person to appear to be wasting away, or to become cachectic.

The terms phthisis and consumption were used interchangeably by physicians referring to the disease.

Probably due to an early symptom of a dry cough, the ancient Greeks may frequently have misdiagnosed it as dry catarrh, or a common cold. This also resulted in catarrh, or inflammation, being suspected as the cause of the disease. (15, page 319, 320, 369)

In fact, Renae Laennec, in his 1919 book "Mediate Auscultation," said that from the time of the ancients, all the way to the late 18th century when many physicians became pathological anatomists and began performing autopsies in search of a better understanding of the diseases that plagued mankind, were tubercles discovered inside the lungs of those infected with the disease.  (15, page 319, 320, 369)

Laennec, therefore, would become the first person to use the term "tuberculosis" to describe the disease.  He used this term even though he most commonly used the term "phthisis pulmonalis."  (9)(13, page 29)

The ancient Greeks also used the term phymata to describe the tubercles observed in pulmonary tissue of humans, cattle, sheep and pigs infected with the pulmonary form of the disease, which became to be known as phthisis (learn how to pronounce it at merriam-webster.com). (9)

Yet the ancient Greeks did not link tubercles with the disease phthisis.  In fact, the ancients, due to their lack of anatomical studies, did not understand what a tubercle was, and therefore it could have been any "accidental production," or abnormal growth, in the lungs.  This would include cysts, cancers, and tubercles. (15, pages 281-283)

Tubercles were also described by Claudius Galen, the greatest physician of the second century A.D. (16, page 285)

In his book "Of Internal Affections," Hippocrates describes the four types of phthisis: (14, page 281)

1. Caused by increased phlegm (pituita) in the chest; recovery rare
2. Caused by great fatigue; is less hazardous, but still very fatal
3. Caused by spinal marrow being caused with blood
4. Caused by drying of the spinal marrow and excess venery, and called dorsal phthisis. (14, page 281)

He offers a treatment for all of them, but for the third he recommends exercise, various roots and flowers, and a fumigation.  For the fourth he recommended large quantities of asses milk mixed with honey, or 14 pounds of cow or goat milk daily for 4-5 days. (14, page 281)

Interestingly, over 2,200 years later, Dr. Rene Laennec would still recommend assess milk as a treatment for the same disease.

However, the type of phthisis we are most concerned with is the first one, which more than likely affects the lungs, and probably the second type.

Because it present with obvious symptoms in life -- cough, fever, fatigue, hemoptysis, chest pain, no appetite, and wasting away, the disease was one of only two pulmonary diseases (pneumonia was the other) to be described by Hippocrates as a disease entity of it's own, with its own remedies. 

Hippocrates, therefore, was the first to describe phthisis as a medical condition, although, like pneumonia, he acknowledged it had been described by the ancients, meaning it had been known for quite some time.  He said it was "The greatest and most dangerous disease and one that proved fatal to the greatest number." (1, page 1)

He also considered it to be a hereditary as opposed to a contagious disease. A later Greek philosopher by the name of Aristotle considered it to be contagious, which opposed general consensus at the time. (10) 

By the year 1819, Rene Laennec said that most people still considered the disease to be contageous, although he was not confident this was the case.

In his book "On the Different Parts of Man," chapter 1 section 1, and then again later in the book, Hippocrates explains that disease resulted when the four humors of the body somehow became imbalanced.  More specifically, he believed phthisis, like asthma, was caused by an over abundance of phlegm being created by the brain. The excess phlegm, when it has nowhere else to go, travels to other organs, and in this case, the lungs.  (14, pages 226, 228, 235, 238)(also see 14, page 269)

Of course, Hippocrates explains, when the excess of phlem results in a fluxation (flowing) of phlegm to the lungs to cause phthisis and suppuration, or this secretions.  It also causes peripneumony (pneumonia and pleurisy).  When it flows to the nose it results in catahhr, or inflammation of the nasal passages (a cold or allergies).  When it flows to the spinal cord, this results in spinal medulla, dorsal phthisis, or what was later termed potts disease.  (14, page 228, 235)

He said that when excessive phlegm flows to both lungs, pneumonia occurs.  When the flow occurs in one lung, pleurisy occurs.  When the flow...

...is carried to a single spot, and enters into the structure of the lungs, phthisis ensues; for when the humour reaches there slowly, bringing consequently but little moisture into them, it thickens, concretes, and drives in the bronchi; it excites cough by adhering to and filling the narrow cavities; rendering thereby an entrance to the air more difficult; from a defect of respiration, oppression of the breast ensues; a pricking sensation is felt in the lungs, which is not experience when the flow from the head to the part is more copious. If the fluxion (flow) becomes great, the whole body becomes surcharged (excessive), and the phthisis is changed to an empyema; and reversely, when the body becomes dry, the empyema (puss in a cavity of the body, particularly the pleural cavity, or the space between the lungs and its protective covering) passes from that state to phthisis. (14, page 238-239)

There are various causes for such an imbalance, one of which might corrupted foods that are consumed.  The corrupted food is mixed with "impure humours," thus resulting in a body that is "imperfectly nourished", resulting "soft parts that are surcharged (over burdened) with humours and receiving only aqueous matters, become engorged and tumid (inflamed or swollen).  (Definitions are from dictionary.com.)

The remedy for the disease, therefore, would be for something to occur, either naturally or by medical intervention, to re-create a balance of these humors.

In his book "On the Different Parts of Man, he said phthisis treated similarly to peripneumonia (pneumonia).  He said:

Peripneumony is to be treated in the same manner. In case of empyema, mild errhines, to excite a discharge from the nose, and thereby relieving the head, are to be employed, and such food as will loosen the bowels; if the disease is thereby arrested, and the humours diminish, we are then to promote expectoration, both by medicine and by appropriate food, by means of which coughing is excited. In order to effect this, the food should be of a fatty and saline quality, with wine of a rough character. Phthisical patients are treated in the same way, with the exception of giving less food at a time, and wine more diluted, so that the debilitated system may not be too greatly heated, and an afflux of humours thereby induced. (14, page 240)

For some forms of phthisis, particularly the type where "whitish sputa are expectorated.  This disease is cured by copious drinking and using the bath; expectorants are employed, and remedies to relieve the pain.  It is cured in seven days, and is not dangerous, nor is diet necessary." (14, page 242)

He did describe fumigations and an inhaler of sorts, but there is no evidence that he employed these for respiratory diseases.

The point of any intervention would be to re-establish the balance of the humours. If one is in excess, as would be the case with phthisis, where this would be the case with phlegm, something had to be done to reduce the amount of phlegm in the body.  Usually this could be accomplished by inducing a productive cough, vomiting, sweating, or bowel movement.

In "Predictions or prognostics," book II, Hippocrates said:

Of phthisis, advanced to the state of cough and suppuration, I shall refer to what I have already said of empyema. If likely to recover, the expectoration (spitting up phlegm) is easy, and should appear white, uniform in colour and in consistence, and free from pituita (thick nasal secretions). Humours (fluids) from the head should flow freely by the nose; fever should be absent, so that nourishment need not be interdicted (prohibited), and no thirst should attend. A daily evacuation of healthy fæces, in amount proportioned to the food taken, should take place; emaciation ought not to occur; the chest should be square and hairy; and the sternum, small and well covered with flesh, should not project. With such accompaniments, there is little danger; without them, death is not remote. In youth, when suppuration (discharge, pus) forms from congestion, or from previous ulceration, or any similar cause, or from a repetition of an abscess, a recovery is not to be looked for, unless there is a combination of nearly all the above favourable signs. Such persons commonly die in the autumn, as is usually the case in all other chronic affections. Women and girls, in whom phthisis occurs from suppressed menstruation, rarely escape. If it occasionally happens, besides the presence of the above symptoms, a perfect and regular return of the catamenia (menstrual condition) must follow, or there is no hope to be entertained. No less fatal in man, woman, and girls, is the suppuration succeeding to a profuse hæmoptysis (bloody sputum). It is by duly attending to all the symptoms mentioned, that a prediction can be given of health or death in phthisis accompanied with suppuration. Those who after hæmoptysis experience less pain in their back and breast, are most likely to recover; for their cough is less frequent, and though fever attends, it is accompanied with but trifling thirst. Nevertheless, the hemorrhage (bleeding) is often renewed, or an abscess is induced with a discharge of blood. When, with pains of the breast, emaciation (being abnormally thin or weak, or wasting away) slowly advances, with cough, and difficult breathing, but unaccompanied by fever or discharge of pus, we must inquire if something of a compact nature and of an offensive odour is not discharged by coughing. (14, page 130, page )

Isocrates (460-338 B.C.) is often considered as the greatest rhetoricians' in Ancient Greece.  His intent was to improve the speech and writings of individuals by instilling virtues.  He was born in 436 BC, seven  years before Plato was born. Like Aristotle, Isocrates also mentioned that phthisis was contagious.  (1)

Daniels said the disease must have subsided in Egypt by the time of ancient Greece, and the disease was not mentioned much in ancient Roman literature, causing historians to surmise the disease was not very common.

However, the Greco-Roman physician Galen did write about the diseaseand he believed it was an "ulceration of the lungs, thorax or throat, accompanied by a cough, fever, and consumption of the body by pus."

He considered the treatment for the malady to be living at high altitudes, like the top of a mountain. This remedy would become a fad from the mid 19th century to the mid 20th century, when the disease would finally be controlled by modern civilization.

References:

1. Norris, Charles Camblos, "Gynecological and Obstetrical Tuberculosis," 1921, New York, London
2. Koehler, Christopher W., "Consumption, the great killer," http://pubs.acs.org/subscribe/archive/mdd/v05/i02/html/02timeline.html
3. "History of TB," New Jersey Medical School, Global Tuberculosis Institute, http://www.umdnj.edu/ntbc/tbhistory.htm
4. Klebs, Arnold Carl, "Tuberculosis," 1909, New York
5. Morton, Samuel, "Pulmonary Consumption," 1834, Philadelphia
6. Flenner, Simon, , "Immunity in Tuberculosis," Annual report of the Smithonian Institution, 1907, New York, page 627 
7. "Captain of the Men of Death," Ulster Med J. 1989; 58(Suppl): 7–9.
8. Sigeris, Henry E, "A History of Medicine," volume I, "Primitive and Archaic Medicine," Second Edition, 1955, New York, Oxford University Press, page 53
9. Seth, Vimlesh, SK Kabra, Rachna Seth, "Essentials of Tuberculosis,"  Third ed., Jaypee Brothers Medical Publishing, 2006, page 3-4
10. Jones, Greta, "Ca;ptain of All These Men of Death," 2001, New York
11. Prioreschi, Plinio, "A History of Medicine," 1991, volume I, "Primitive and Ancient Medicine," Edwin Mellen Press, Chapter VII, "biblical Medicine," page 514
12. Landau, Elaine, "Tuberculosis," 1995, New York, Chicago, London, Sydney, Franklin Watts, pages 13-32
13. Daniel, Thomas M., "Pioneers in Medicine and their impact on Tuberculosis," 2000, University of Rochester Press
14. Hippocrates, Claudius Galen, writers,  John Redman Coxe, translator, "Hippocrates, the Writings of Hippocrates and Galen," 1846, http://oll.libertyfund.org/titles/1988, accessed 7/6/14, also see the book online at Google books, Philadelphia, Lindsay and Blakiston
15. Laennec, Rene, "Mediate Auscultation," translated by John Forbes, Notes by professor Andral, 4th edition, 1838, New York, Samuel S. and William Wood
16. Laennec, Rene, ibid, from the notes by Dr. M. Andral

Further reading:

• essentials of tuberculosisi in children

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400 B.C: Hippocrates defines pneumonia

Pneumonia is sometimes referred to as one of the oldest diseases known to mankind.  It would seem wise to presume that so long as a person, or a species, has lungs, that the possibility of them becoming infected, and inflamed, would always exist.  If this is true, then pneumonia must have been a common cause of death since the beginning of mankind.

During the rare opportunities that medicine men, or priest physicians, or later physicians, had to dissect a person who died of dyspnea or asthma, a whitish hue to the tissue of certain lobes, which may have been hardened, would have been observed.  They also would have observed colorful secretions in the airway.  In this way, it was easy for the first physicians to distinguish pneumonia from other diseases.  

Despite the disease going that far back, it wasn't described for the medical profession until Hippocrates wrote of it in 400 B.C.  However, we know that it was described long before him because he said it was "described by the ancients."

In attempting to distinguish between the two diseases, Hippocrates might try to shake the patient, a procedure called succussion.  This would allow the physician to hear the puss in the pleural cavity rattle.  He said any keen physician should be able to diagnose pleurisy by this method.

However, it must not have been that easy, as various Greek physicians, including Hippocrates himself, observed that it was difficult to differentiate between the two, and for this reason they were generally grouped together as peripneumonia, or peripneumony.  (8, page 192)

They knew pneumonia was inflammation in of one lobe of the lungs, and they knew pleurisy was inflammation in the pleural cavity.  Yet while pneumonia was accompanied by a fever and a pain in the chest, pleurisy was accompanied by a fever and a sharp pain in the side.

We now know that sometimes the two diseases appear independently of one another, although sometimes they appear together.  So its understandable that ancient physicians would have had trouble differentiating between the two, particularly lacking the ability to perform autopsies.

Of course, it was also quite common for both of these diseases to also be confused with asthma, which is our umbrella term for all causes of dyspnea other than pneumonia and phthisis.  So getting an accurate diagnosis was difficult regardless of the efforts of the physician.  (2, page 3)

Of peripneumony, Hippocrates wrote:

Peripneumonia, and pleuricic affections, are to be thus observed: If the fever be acute, and if there be pains on either side, or in both, and if expiration be if cough be present, and the sputa expectorated be of a blond or livid color, or likewise thin, frothy, and florid, or having any other character different from the common.

Dictionary.com describes pneumon as latin for lung or lung and pneuma as latin for lung.  So pneumonia refers to a condition of the lung.

Pleurisy was defined by the Ancient Greeks as inflammation of the pleural cavity, and they recognized symptoms of pleurisy and pneumonia as a sharp pain in the side.

The treatment of Hippocrates was generally the same for all diseases, and consisted of good hygiene, a good diet, rest, exercise, and plenty of sleep.  These were supposed to help nature be the remedy, or the means of returning the humours to homeostasis.

However, if those did not work, and depending on the stage of the disease of the illness, age of the patient, color of the sputum, and season of the year, any of the following may be the remedies.  (6)

• Bleeding
• If fever, the bowels were opened with clysters
• If pain, hot water in a bottle or bladder, a sponge of hot water, or cataplasm of linseed was applied to the hypochondrium
• Linctus containing galbanum and pine fruit in Attic Honey or...
• Sothernwood in oxymel
• Oppaponax (a bitter resin with a garlic taste) mixed in oxymel
• Drink of ptisan made from huskey barley and mixed with oxymel

Hippocrates was well aware of when the disease was getting better or worse, as noted in the following passage.  (6)

"When pneumonia is at its height, the case is beyond remedy if he is not purged, and it is bad if he has dyspnoea, and urine that is thin and acrid, and if sweats come out about the neck and head, for such sweats are bad, as proceeding from the suffocation, rales, and the violence of the disease which is obtaining the upper hand, unless there be a copious evacuation of thick urine, and the sputa be concocted; when either of these comes on spontaneously, that will carry off the disease."

Hippocrates noted that death from pneumonia usually occurs on the seventh day.

References:

1. "Leading Cause of Death, 1900-1998," http://www.cdc.gov/nchs/data/dvs/lead1900_98.pdf
2. Sturges, Octavius, "The Natural History and Relations of Pneumonia," London, 1876
3. "History of Pneumonia," The British Medical Journal,  Jan. 19, 1952, pages 156-158
4. Schmitt, Steven K., "Oral Therapy for Pneumonia:  Who, When, and With What?" editorial, Journal of Clinical Outcomes Management,  March, 1999, vol 6, No 3, pages 48-50
5. Bellis, Mary, "The History of Penicillin," http://inventors.about.com/od/pstartinventions/a/Penicillin.htm
6. Marrie, Thomas J, "Community Acquired Pneumonia," 2001, New York, chapter one by Jock Murray, "The Captain of Men and Death: The History of Pneumonia."
7. Auld, A.G., "The Pathological Histology of Bronchial Affections," The Lancet, Aug. 6, 1892, page 312
8. Allbutt, Clifford, ed, A System of Medicine, 1909, Toronto, chapter on "Lobar Pneumonia,"  by P.H. Pye-Smith, pages 191-205

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400 B.C.: Diagnosing lung diseases with succussion

One of the first techniques ever devised to help physicians diagnose lung disease was succussion.  This is a technique where the physician would grab the patient by the shoulders, shaking the patient so any fluid that may have accumulated within his body -- particularly the lungs -- could be heard.

While this technique was probably used earlier, it didn't become a common procedure until it was described by Hippocrates at around 400 B.C.  Calvin Newton and Marshall Calkins, in their 1854 book, said:

"The term signifies a shaking; and the act consists in suddenly agitating a patient with the view of detecting the existence of fluid in some one of the cavities of the body, -- particularly, one of the pleural sacs (lungs). Seizing, by the shoulders, an individual, as he is ordinarily seated, strongly jolt or shock his whole frame. In this way, the sound of a contained fluid may sometimes be heard, like that of a liquid in a cask or bottle that is forcibly agitated. This has been called the metallic splash. Sometimes, the patient in bed is able to shake himself as to give the splashing sound of the water, in the thorax. The art was known to Hippocrates and has, hence, sometimes termed Hippocratic succussion."

Newton, however, explains that there was little reason to use this method because there were better techniques available to detect fluid inside the body, such as percussion and auscultation with a stethoscope, both of which had been well established by 1854.

In his book "On the Different Parts of Man," that disease is a result of an imbalance of the humors.  Respiratory diseases, particularly phthisis, pleurisy and pneumonia, was caused when an abundance of phlegm resulted in the fluxation, or flowing, of excessive phlegm to the lungs.  (2, page 239)

When the humours flowed to only one lung, this usually resulted in pleurisy and phthisis, which was in infection that resulted an infection, or pus, forming in the pleural cavity, or the space between the protective covering of the lungs and the lungs.  Hippocrates said "on shaking the body, we can perceive a fluctuation, and hear a sound. (2, page 239)

He said:

We known an empyema (pus in a cavity of the body, particularly the pleural cavity) by these indications.  A patient at first feels a pain in the side, pus collects, and the pain continues with cough and expectoration of pus, and difficult respiration. If, however, the pus has not yet found an exit, concussion (succussion) of the body renders it perceptible in its fluctuation, by a similar sound to that of fluid shaken in a bottle.  (2, page 239)

Succussion is no longer used by physicians for the same reason Newton described in his book.  Could you imagine a doctor shaking you like that?

References:

1. Newton, Calvin, Marshall Calkins, "Thoracic diseases: their patterns, diagnosis and treatment" Worcester, published by D. and M. Calkins, page 89
2. Hippocrates, Claudius Galen, writers,  John Redman Coxe, translator,http://oll.libertyfund.org/titles/1988, accessed 7/6/14, also see the book online at Google books, Philadelphia, Lindsay and Blakiston

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400 B.C.: The Hippocratic Inhaler

The first inhaler was probably invented long before Hippocrates walked the earth in the 5th century B.C.  Yet the first time it was ever recorded was by Hippocrates, or at least by one of the writers of the Hippocratic Corpus.  

The inventor is unknown to history, although one might suspect that a young Greek priest learned about it on one of his journeys, and it appeared to him in a vision at the Aesclepion at Cos.  He provided it as a remedy and it worked for what he was told it would work for.  It was then recorded in the votive tablets.

Many years later, while making his own effort to record the wisdom of the ancients, Hippocrates would have learned of this inhaler.  He wrote about it in his Hippocratic Corpus.  

Of course he didn't refer to it as an inhaler, of course not, as the term wasn't coined yet.  Also, chances are pretty good the inhaler he learned about was not used for asthma, or even asthma-like symptoms, but some other unknown malady.  Yet it may have been used for asthma at some point.

So, in the Corpus Hippocrates mentions this inhaler-like device.  The model basically consisted of a jar with a hole in the lid for the insertion of a hollow reed for inhaling the contents. The mouth was saved from burns by use of a soft sponge or egg shells between the mouth and reed.  (1, page 461)

Boiling water would be inserted into the jar, perhaps a recipe of medicines, the lid placed atop the jar, the reed stick inserted through the hole.  The patient would inhale by placing his mouth on the reed stick.  It was a simple design and must have worked quite well, because it was the design used by physicians for many years.

Hippocrates also described fumigations, which probably would have been of smoke or steam.  This treatment might have been more readily available than the inhaler.  (2, page 241)

However, it should be noted that the most common use of fumigations and the inhaler was probably not for respiratory ailments.

For instance, he recommended fumigation to induce menstuation in virgins. He
recommended fumigation, among other treatments, as a option when a female had pituitous (mucousy) menstruation, or when female hysteria results form displacement of her uterus, which might cause sterility. It was also recommended when a female could not feel her infant moving in the uterus at four or five months. He also recommended it for severe ulcers, among other similar non-respiratory ailments. (2, page 300, 304)

He did, however, recommend fumigations for certain types of phthisis, although mainly for spinal tuberculosis and not the pulmonary type. (2, page 281)

He also recommended inhalation for quinsy, or the various diseases that causes swelling of the throat. He also recommended inhalation for angina. (2, page 281, 260-262)

Getting back to the inhaler, many believe it was the Hippocratic Inhaler that was fine tuned during the 19th century when the first two inhalers were manufactured and placed on the market.

References: 

1. Glasgow Medical Journal, Volume 14 By Glasgow and West of Scotland Medical Association, Royal Medico-Chirurgical Society of Glasgow
2. Hippocrates, Claudius Galen, writers,  John Redman Coxe, translator, "Hippocrates, the Writings of Hippocrates and Galen," 1846, http://oll.libertyfund.org/titles/1988, accessed 7/6/14, also see the book online at Google books, Philadelphia, Lindsay and Blakiston

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370 B.C.: The dogmatic school of medicine

While Hippocrates is credited with creating the humoral hypothesis, it was his sons, Thessalus and Draco, who are credited with creating the first school, or sect, of medicine: the Dogmatic School of Medicine. (1, page)

There were various names for this school, depending on the era it was being described, and who was describing it.

Since it was based on the writings of the Hippocratic writers and Hippocrates himself, it was sometimes called the Hippocratic school, and physicians called Hippocratici. 

Since it was based on philosophers who believed it was necessary to rationalize about medicine, it was sometimes called the Rationalist school, and physicians called rationalists.

Since it was based on the belief that health was determined by a balance of the four humors (blood, phlegm, black bile and yellow bile) of Hippocrates, and diseases caused by an imbalance thereof, it was often called the Humoral school, and physicians called humoralists.

And, finally, since it was based on the dogma of Hippocrates, it was also called the Dogmatic school, and physicians called dogmatists or dogmatici. 

Regardless of the name, the general idea here is best explained by medical historian Edward Withington in 1894:  (3, page 57)

The ancient Greeks loved talking; his mind was more philosophical than scientific, and he preferred to speculate on things in general rather than to investigate particular facts... A Hippocratic writer had said, 'The physician who is also a philosopher is godlike.' This became the motto of the dogmatic school, was made the excuse for an immense amount of useless speculation, and was finally taken as the text of a special treaties by Galen himself. (3, page 57)

The dogmatic school of medicine was generally taught at the School of Cos, and was based on the opinions of Hippocrates, yet it was also based on the Stoic philosophy. This led to much "useless speculation," (3, page 57)

Part of this "useless" speculation was that diseases were caused by imbalances of the four elements and humors, and remedies were a means to re-establish the balance.  Remedies may be as simple as a lifestyle change, and as harsh as bleeding and purging.  Any particular remedy did not require any specific evidence that it worked.

You can  also learn more about Hippocratic medicine by reading about the medical wisdom of Hippocrates.

Followers of this school believed in the importance of studying anatomy, and often performed autopsies on animals such as pigs, monkeys and apes.  They performed autopsies on humans if possible, although this was frowned upon and illegal in the ancient world.  Human autopsies were performed when permission was granted, and in such cases was usually performed upon stolen corpses or, worse, live prisoners.

They had a basic understanding of human anatomy: the layout of the main organs, the vessels that line the body.  They understood the importance of correlating medicine with physiology.  The obvious problem with their school was the reliance on opinions as opposed to observation, experience and science.  Of course when the school was formed there was no knowledge of any of those things.  (3, page 60)

By about 50 A.D., when most referred to it as the Humoral or Rational School, it was under fierce competition by four other schools that also formed in Greece. Despite this competition, the basic tenants of this school would be followed by physicians all the way to the middle of the 18th century.

References:

1. "Rationalism (philosophy), Encyclopedia Britannica.com, http://www.britannica.com/EBchecked/topic/492034/rationalism
2. Withington, Edward Theodore, "Medical History from the Earliest Times," 1894, London
3. Watson, John, "Medical Profession in Ancient Times, "
4. Magill, Frank N., editor, "Dictionary of World Biography," Volume I: The Ancient World, 1998, Salem Press Inc., California
5. Meryon, Edward, "History of Medicine: comprising a narrative of its progress from the earliest ages to the present and of the delusions incidental to its advance from empericism to the dignity of a science," volume I, London, 1861,
6. Adams, Charles, Kendall, editor, "Johnson's Universal Cyclopedia: A new edition," volume V, A. Johnson Company, New York, 1894
7. Garrison, Fielding Hudson, "An introduction to the history of medicine: with medical chronology, Bibliographic data and test questions," 1913, Philadelphia and London, W.B. Saunders company
8. Neuburger, Max, writer, "History of Medicine," 1910, translated by Ernest Playfair, Volume I, London, Oxford University Press

400 B.C.: Did Hippocrates recognize allergies?

While hay fever was not mentioned until the 19th century, and allergies not defined until the 20th century, the signs and symptoms of allergies were well known to physicians of the ancient world.  Perhaps the first allusion to this was by Hippocrates during the 5th century.

Claude Lenfantt, in his introduction to the book "The Immunological Basis of Asthma, quotes Hippocrates as saying: 

Cheese does not harm all men alike, some can eat their fill of it without the slightest hurt, nay, those it agrees with are wonderfully strengthened thereby.  Others come off badly.  So the constitution of these men differ, and the difference lies in the constituent of the body which is hostile to cheese, and is roused and stirred to action under its influence. (1, page introduction)

Since Hippocrates probably obtained his medical wisdom from his ancestors, who were probably teachers at the Asclepion at Cos, we can probably surmise that physicians going back to the early ancient world observed the symptoms of allergies.

Surely allergies caused grief and suffering for those afflicted with it, this would have been minor compared to all the diseases that plagued the ancient world.  So allergies, even more so than asthma, was essentially ignored by the medical community.  The symptoms were probably recognized and brushed aside as catarrh, or the common cold.

References:

1. Lenfant, Claude, author of introduction, Bart Lambrecht, Henk Hoogsteden, Zuzana Diamant, editors, "The Immunological Basis of Asthma," Lung Biology of Health and Disease, Volume 174, Claude Lenfant, executive editor, 2003, New York, Marcel Dekker, Inc. 

400 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 acomposite 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.

As far as we know, the first known person to use the term 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

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, like a 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.  Diseases extricated after the death of Hippocrates were scoliosis, cardiac asthma (heart failure), kidney asthma (kidney failure), bronchitis and emphysema.

It's also interesting to note that diseases that caused curvature of the spine, such as scoliosis, were also considered as asthma.  They caused dyspnea because they resulted in less space for the lungs in the chest.  As these people age, it can lead to dyspnea and even an early death.  In fact, 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 observed signs of the common cold, bronchitis, and allergies.

He wrote a treatise "Of Epilepsy."  Prior to his time, the condition 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 any other." (11, pages 201-203)

Hippocrates believed that instead of being a divine disease, epilepsy was caused had a natural cause, which started by an increase of phlegm in the brain that ultimately made its way to the veins and impeded the flow of pneuma to the brain. He said:

This malady, then, affects phlegmatic people, but not bilious. It begins to be formed while the foedtus 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 writer) 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 defecation, 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 spasmodic in nature.  In other words, he alluded to what would later be referred to as the spasmodic 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 spasmodic 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 spasmodic 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 with 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 physician born into the 2nd century after the birth of Christ by the name of 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 ver- tebra 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 response
• It was hereditary
• It was convulsive or spasmodic 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 shaken his patient in order so that he could hear if he had increased phlegm in his chest, a procedure called succussion.

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 may determine what changes occurred to the humors of the patient's 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 for them all.  He perhaps was the first to allude to nerves as a trigger for asthma, when he wrote, "The asthmatic should guard himself against his own anger” (10, Douwles)

In effect, Hippocrates was the first to allude to both the spasmodic theory of asthma and the nervous theory of asthma. While the nervous theory of asthma would become the main theory through most of history, the spasmodic theory would gain steam in the 19th century. Both, however, are still considered viable theories to this day, although with major modern adjustments of course. Bear with me, as I will delve into these two theories as our history rolls along. 

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
• A draught of white hellebore 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 vinegar 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 waits for the asthma episode to dissipate.

Click here for more asthma history.

References

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?" ezinearticles.com, http://ezinearticles.com/?Who-Discovered-Asthma-Hippocrates-Or-Galen?&id=1381520, 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
20. Douwes, et al., "Asthma Nervosa: old concept, new insight," European Respiratory Journal, 2011, http://erj.ersjournals.com/content/37/5/986, accessed 7/18/17