1675:Willis narrows asthma definition

Thomas Willis (1621-1675)

In the 19th century Dr. Samuel Gee (1839-1911) made a gallant effort to update the definition of asthma for physicians during his era. He wrote fondly of 17th century physician, Dr. Thomas Willis, giving him credit as "innovator of the doctrines of the ancients." (1)

Gee described, in 1899, that prior to the 17th century, asthma was considered "any kind of panting, gasping, pursy breathing such as follows on running on exertion." (1)

Back then asthma was still considered to be a disease nothing more than a disease caused by the spirits. Yet in 1678, Willis described asthma as "obstruction of bronchi by thick humors, swelling of their walls and obstruction from without." (2)

So Willis was given credit for the evolution of asthma as more than simply a disease of dyspnea and wheezing.  Other doctors may have helped to advance the definition (such as van Helmont), yet it was Dr. Willis who made asthma a unique illness in and of its own, such as Tuberculosis and Epilepsy were unique illnesses treated with unique remedies.

"Hence," Gee wrote, "Asthma and dyspnea were synonyms for most of the older physicians.  A few, such as Celsus (25 B.C.-50 A.D.), signified by asthma the highest degree of dyspnea, but this was all; asthma was never regarded as a special sort of dyspnea." (1)

For Gee, ancient definitions of asthma from Hippocrates to Galen to van Helmont were inaccurate until we get to Thomas Willis of the 17th century.  In his book , "Rational Pharmaceutic," which was published the same year as his death in 1675 (note the trend),  Willis explained that all ancient and modern physicians up to his time acknowledged only one kind of asthma, and this was pneumatic asthma.

Gee explained that pneumatic asthma was described by Willis as when the lungs were "obstructed or not open enough."  Gee said that the ancients regarded all asthma as "pneumatic and dependent on bronchial obstruction." (1)

He said the ancient definition of asthma is of little value in modern times (for Gee modern times would be 1899).  Yet, "It is interesting to note that those most conservative of people, the illiterate, continue to use the word in the sense of Hippocrates and Galen." (1)

However, we must note that it was illegal for the Ancient Greeks and Romans to dissect human bodies, and even in the 17th century it was very risky business to publish ideas that opposed the beliefs of the church or ruling parties (hence the publishing of Willis's works posthumously).

We see this often as we follow the history of science, medicine, and asthma.  It's perhaps this stubbornness of mankind that we can give credit for the slowness to which the term asthma was defined, and why it took until 1901 for good asthma medicine to be discovered.

Orville Harry Brown, in his 1917 book, explained that Willis attributed to the cause of asthma "as some humor in the blood. (5, page 27).

Ernst Shmiegelow, in his 1890 book, said Willis may have been one of the first to explore the idea of the diaphragm as being the cause of asthma, and therefore may also be the creator of the diaphragmatic theory of asthma which will be defined later in this history.  (6, page 4)

Gee said Willis described three forms of asthma: (1, page 817)

1. Pneumatic Asthma:  Dyspnea is a result of air passages in the lungs being obstructed or not open enough
2. Convulsive Asthma:  The primary fault of dyspnea comes from the lungs themselves, "in the moving fibres or muscular coats of the air vessels or in the diaphragm and muscles of the chest or in the nerves of the lungs and chest or of the origin of those nerves in the brain."
3. Mixed Asthma:  Both pneumatic and convulsive.

Gee said that in defining convulsive asthma, Willis pondered all the theories before his time and incorporated them into his newly defined convulsive asthma, which...

...was soon laid hold of.  The term 'asthma' came to be reserved for the exclusive denomination of that form of the disease which was believed to be spasmotic; and this is the sense in which the word is still used by most persons even in our own day.  (1)

I must continue to remind my readers that nervous asthma was generally thought to be synonymous with spasmotic or convulsive asthma.  By this the medical community believed the the fit of asthma was caused by nervous pathways from the brain as a result of something exciting these nervous pathways.

Barry Brenner, in 1999, said Willis also made an "association between food, emotion, heredity, and asthma." In fact, it was in 1672 that Willis described emotion as bringing about an asthma attack.  (3)

Way back in the 12th century, Maimonides described asthma as a nocturnal disease. In the 17th century there were many references of asthma as a nocturnal disease. T.J.H. Clark, in his 1987 book called "Diurnal Rhythm of Asthma, said Willis....

...blamed the heat of the bed as the cause of nocturnal asthma and he advised leaving the bed and sleeping in a chair.  By contrast, Maimonides recommended celibacy. (4)

So, while we know Jean Baptiste van Helmont was the first person to write about nervous asthma, Willis is given credit.  Regardless, the ideas of van Helmont and Willis regarding asthma would grow roots in the minds of the medical community that would impact how asthmatics were treated long into the 20th century.

References:

1. Gee, Samuel, "Bronchitis, Pulmonary Emphysema, and Asthma,", Lancet, March 25, 1899, page 817
2. Salvi, Sundeep S., "Is Asthma Really Due to a Polarized T Cell Response Toward a helper T-Cell Type 2 Phenotype," American Journal of Respiratory and Critical Care Medicine, Oct. 15, 2001, vol. 164, no. 8, pages 1343-6
3. Brenner, Barry, "Emergency Medicine," 1999, New York, page 6 (Brenner wrote 
4. Clark, T.J.H., "Diurnal Rhythm of Asthma," (American College of Chest Physicians), 1987,  page 1375
5. Brown, Orville Harry, "Asthma, presenting an exposition of nonpassive expiration theory," 1917, St. Louis, C.V. Mosby Company
6. Shmiegelow, Ernst, "Asthma, considered specially in relation to nasal disease," 1890, London, H.K. Lewis
7. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1921, 3rd edition, Philadelphia and London, W.B Saunders Company
8. 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; Ramadge discusses Thomas Willis's views on asthma on pages 93-94.  He also mentions him various other times in his book. 

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1645: Van Helmont narrows asthma definition

Jean Baptiste van Helmont (1580-1644)

Galileo set the way for others to question old scientific and medical superstitions that were regarded as facts, and one such physician/ scientist/ alchemist was Jean Baptiste van Helmont, who, in 1579, was born into the dawn of the Scientific Revolution in Brussels.

He was the younger son of a noble family, and his father died in his second year. He entered the University of Louvain (Leuven) at a young age, and graduated from his studies in mathematics, astronomy, astrology, and philosophy at the young age of 17. (3, page 260) (4, page 113-114)(7)

He had an opportunity to become the imperial physician, but he declined it because medicine failed to heal him when he obtained scabies from a girl. Instead he decided to "spend his time by fasting, supplication and prayer, and in poverty. He chose the poverty of Christ, giving to his sister all his worldly possessions." (4, page 115)

He then spent time as a Capuchin friar just prior to studying law, botany and medicine. Once this task was completed, he traveled to Switzerland and Italy (1600-1602) and then France and England (1602-15), and then he received his medical degree in 1599. As a physician he was "unwilling to accept money from his sick fellow-man in return for so doubtful an art." (4, page 114)(7)

He put to use his medical skills during a plague that broke out in Antwerp in 1605. (7) This must have earned him quite a bit of fame.  It was also about this time that he was introduced to a person who introduced him to Paracelsus (1493-1541), and he studied his works "zealously." (4, page 114)

Perhaps due to the fame he earned by his travels and experiences, he was offered many attractive jobs from princes and archbishops, although he turned all of these down in 1609, claiming the he did not want to live in the "misery of my fellow men." (7)

It was that same year, in 1609, that he abandoned poverty and Christ, and married a rich heiress by the name of Margaret van Ranst. Through her he inherited several estates, and he retired to one of them, leaving the medical profession to devote his entire life to "chemical science" and transforming the works of Paracelsus. (4, pages 14-15) (7)

By this he became a chemist, although, more than likely, he was an alchemist, following in the footsteps of Paracelsus, of whom, many agree, was also an alchemist.

Unlike Paracelsus, van Helmont didn't believe in ancient Greek theories.  In fact, he became the first to dismiss the idea that asthma (and diseases in general) was a disease caused by an imbalance of the humors and instead was a disease caused by a narrowing of the pipes in the lungs. It was this view that made him a very controversial person during his lifetime.

 Historian Fielding Hudson Garrison explains van Helmont this way:

Like his master, Paracelsus, van Helmont believed that each material process of the body is presided over by a special archaeus, or spirit (which he calls Blas), and that these physiologic processes are in themselves purely chemical, being due in each case to the agency of a special ferment (or Gas). Each Gas is an instrument in the hands of its special Blas, while the latter are presided over by a sensory-motive soul (anima sensitiva motivaque), which van Helmont locates in the pit of the stomach, since a blow in that region destroys consciousness. (3, page 260)

Bradford explained him as follows:

Van Helmont transmuted the fancies of Paracelsus into a sort of mystic and pious system based on chemical principles. He was a considerable chemist. He thought that air and water were the elements; from the water everything on earth takes its origin—the world is the creation of God.(4, pages 114-115)

In order to prove the basic element of the earth was water he performed an experiment where he grew a tree in a a tub for five years and gave it nothing but pure water. He weighed the tree and soil before the experiment, and in the end the soil weighed the same and the tree had gained 160 pounds. He attributed the weight gain of the tree as being due to water. While his conclusion may not have been completely accurate, some historians refer to him as the father of biochemistry because of this experiment. (9)

Bradford continued:

Disease is something active and is caused by the fall of man. The spirit of man came from God, but on account of the fall became so corrupted that a lesser spirit in man gained control. There was next lower a perceptive soul, and below that a something which he called Archaeus; then there is also Gas which arose by the influence of the Archaeus on water. To Van Helmont we owe this word Gas. (4, page 115) 

The term "gas" he derived from the Greek word for chaos.  Due to his experiments with gases he is considered by many historians as the father of pneumatic (air) science.

One of his most famous experiments was when he burned charcoal and produced the substance carbon dioxide. He explained this was the same product produced from fermenting musk, which rendered the air inside caves as unbreathable. Yet at that time he did not use the word carbon dioxide, he used instead the word gas sylvestre.

He also described other gases, such as carbon monoxide, chlorine gas (prescribed by later physicians as an asthma remedy), digestive gases, sulfer dioxide, and a "vital" gas in the blood that we now refer to as oxygen.

Perhaps one of the reasons van Helmont studied air was that he was an asthmatic.  He generally believed asthma was a physical disease of the lungs caused by factors outside the lungs, such as substances one might come into contact with, substances in the air, and substances affecting the mind.

Orville Brown explains how van Helmont suspected the "archeus" was the cause of asthma: (5, page 27)

"Archeus"—a something—a vital spirit—was enshrined in the stomach, and when disturbed, was responsible for disease by sending forth a peculiar fluid, which, reaching the lungs, caused asthma.  (5, page 27)

To grasp a more complete understanding of this system of van Helmont, I will once again refer to Thomas Bradford, who said:

Van Helmont declared a very mystical and fanciful philosophy; the spleen and the stomach were the rulers over the body. The spleen presided over the abdomen, the sexual organs; the stomach over sleep, waking, and folly. This Archaeus also possessed a great power both in man and in animals. Disease depended on a perverted action of the Archaeus. (4, page 115)

More specifically, Walter Pagan, in his 1982 book about van Helmont, said van Helmont believed asthma was caused when a "specific disease semen has planted its root; in the present case (for asthma) a semen that closes the peripheral pores through which air passes from the lungs into the chest cavity.  It is a semen with the property of causing contraction of members and parts."  (2, page 175-176

That this has occurred, Pagan said of Helmont's theory, "is eveident with the phenomena associated with asthma," such as: (2, page 176)

• Diuresis
• Diarrhea 
• Gurgling of the gut
• Contraction around the gums (2, page 176)

Pagan likewise said that because the lung contracted, Helmont referred to asthma as "epilepsy of the lungs." (2, page 176)(1, page 216)(8, page 374)

He also called it this because asthma was observed to be "latent for long periods, only to provoke on special occasions attacks of contraction that chiefly concern one organ; in this case the lungs, in real epilepsy the nervous system." (2, page 176)  

Pagan added one other thing about the "specific disease semon" that causes asthma:

Basically, however, neither of these is a localized ailment but one conditioned by the influent archeus, the vital principle of the organism as a while. This is shown by the associated symptoms outside the lungs. But the anatomical changes must be looked for in the lungs, where the poison attacks directly, and where they are produced as at a specific seat. To that extent asthma (as indeed every other disease) is a local and localized affair. Its poison irritates in the same way cantharides do, and is essentially identical with the poison of epilepsy, but not strong enough to produce the latter. (2, page 176)

It is believed by many historians that he was the first to link asthma with hysteria, and therefore should be given credit as the father of the nervous theory of asthma.  But he usually doesn't get this credit, perhaps because of the controversial nature of his work, and the fact hat he fad no followers.

Most historians give Thomas Willis, his contemporary, credit for creating the nervous theory of asthma.  This is usually the case even though Willis mentioned nervous asthma several years after van Helmont did.  Yet this is just the way history is, sometimes giving credit for discoveries to the most popular person as opposed to the correct person.

Bradford said van Helmont's remedies for just about any disease were: (4, page 115)

• Conjuratoins
• Charms
• Prayer
• Power of god  (4, page 115)

He also used "earthly medicines," such as: (4, page 115)

• Opium
• Mercury
• Antimony
• Wine (for fevers)  (4, page 115)

Barry Brenner, in his 1999 history of asthma, said:

(Van Helmont) noted that the bronchi were the origin of asthma, and that inhaling dust and fish in certain individuals brought on attacks. He noted that the bronchi would react with spasm to dust, especially from the demolition of houses and temples. He described a monk who, while eating fish fired in oil, fell down, deprived of breathing, "so that he was scarce distinguished from a strangled man." The concept put it in conflict with the official Church view of internal humors as the cause of disease, and he was condemned to death until he recanted. (6, page 5-6)

Once he retired he dedicated about seven years to chemical research, and then he spent the rest of his life in "relative solitude and mostly in peace."  (7)

This was despite the fact that most of what he discovered, and most of what he believed, was contrary to the views of the church.  It was due to such controversies surrounding his work that he waited until he was on his deathbed to give his works to his son to edit and publish. So all of what was described above, all he accomplished in his life, was never published until after he was dead.  (7)

Van Helmont had an illustrious mind, one who decided to do what he thought was right as opposed to what was popular.  Surely this caused some controversy during his lifetime, but it was to the benefit of future generations.

References:

1. Nulan, Sherwin B, "The mysteries within: a surgeon explores myth, medicine and the human body," 2000, New York, Simon and Schuster
2. Pagan, Walter, "Joan Baptista Van Helmont: Reformer of Science and Medicine," 1982, UK, Cambridge University Press\
3. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1921, 3rd edition, Philadelphia and London, W.B Saunders Company
4. Bradford, Thomas Lindsley, writer, Robert Ray Roth, editor, “Quiz questions on the history of medicine from the lectures of Thomas Lindley Bradford M.D.,” 1898, Philadelphia, Hohn Joseph McVey
5. Brown, Orville Harry, "Asthma, presenting an exposition of the nonpassive expiration theory," 1917, St. Louis, C.V. Mosby Company
6. Brenner, Barry E, author of chapter one in "Emergency Asthma" called  "Where have we been? The history of acute asthma," 1999, New York, Marcel Dekker, Inc
7. "Jan Baptista van Helmont," Britannica.com, http://www.britannica.com/EBchecked/topic/260549/Jan-Baptista-van-Helmont, accessed 11/11/13
8. Gill, M. H., "Review and Bibliographic Notices: "On the spasmotic asthma of adults," by Bergson, published Gill's book, "The Dublin Quarterly Journal of Medical Science," volume X, August and November, 1850, Dublin, Hodges and Smith, pages 373-388
9. "History of Chemistry," historyworld.net, http://www.historyworld.net/wrldhis/PlainTextHistories.asp?ParagraphID=kpt, accessed 7/6/14

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1698: Floyer redefines asthma, upholds supernatural

Sir John Floyer

The early 17th century centered around a struggle by Western men who were losing their enchantment with the old world in favor of truths obtained by scientific progress and thought. John Floyer was born into this world in 1649 and he rejected it.

In fact, it was because he rejected it that he became one of the most interesting and popular personalities of his generation. He put forth a defense against modern logic and a defense for Ancient ideas, yet at the same time he provided a stunningly accurate description of asthma based on his own experience and experimentation

Floyer lived at about the same time as Jean Baptiste van Helmont and Thomas Willis, yet it was Floyer's ideas regarding asthma that were more readily accepted by his generation. The reason was partly because Floyer had asthma and he used his own experiences to describe the disease.  Yet more likely because he disregarded science and accepted old superstitions that were popular, while the other two endorsed science.

Floyer rejected the ideas of van Helmont and Wilson and other "quacks" because they "know little of Anatomy, and the Nature of Animal Humours."

He also accepted the ideas of Hippocrates and Galen that all diseases were caused by some external poison that caused an imbalance of the humors:  black bile, yellow bile, phlegm and blood.

Floyer's Treaties of the Asthma (a)

Since this was the accepted dogma of the day -- a paradigm that medicine was still stuck in at the time -- Floyer's ideas were much easier for other physicians to accept.  

Floyer was born in 1649 in the small town of Staffordshire, England, the same year as the execution of Charles I.  He suffered from asthma as a child and through much of his adulthood, and it was because of this he would later take up the study of asthma. (2, page 248)

He received his medical degree from Oxford in 1680.  Shortly thereafter he returned to Lichfield which was only a few short miles from his birthplace and became an important member of the British society, and he was even knighted by James II in 1686. (2, page 248)


He was an ardent supporter of cold water bathing, and in n 1701 he published "A History of Cold Bathing: Both Ancient and Modern." He would often recommend this book to his patients, including those with asthma.

In 1682 Andreas Cleyer's Specimen medicinae Sinicae introduced the West to the ancient Chinese method of counting a pulse to diagnose diseases.  Floyer liked this idea, and he expanded it and made taking a pulse a routine task when assessing a patient.

To make the task easier he invented a "pulse watch" that had a second hand that ran for one minute.  Alex Sakula, "Sir John Floyer's A Treatise on Asthma (1698)," said that one of the reasons this "pulse watch" was so important for his study was because he believed that each disease was associated with a specific pulse. (1, page 248)

Floyer wrote about his watch in "The Physician's Pulse Watch" volume 1, in 1707.  You can read about it in more detail here.  The pulse watch was advanced many times even during Floyer's own life, and it soon became a popular site to see your neighborhood physician with a pocket watch. The practice of taking vitals, a pulse and respiratory rate, became commonplace.

The art of watching the hands of a watch revolve is often attributed to Sir John Floyer.

When it came to asthma, Floyer was not a fan of modern remedies that were prescribed by other physicians of his day, such as Van Helmont and Wilson. In fact, he flat out rejected many of them, and instead preferred the more supernatural remedies of Hippocrates and Galen.

Yet while he preferred the supernatural, he was also the first asthma expert to make the case for asthma as a separate disease, as compared to the common rubric term for all that is short of breath.  He made this case in his 1698 book "A Treatise of the Asthma."

In this book, Floyer described respiration as...

...preparing the blood or air vessels by tumours or by injury to the muscles of respiration or to the 'spirits, moving those Muscles.'

He described asthma this way:

When the Muscles labour much for Inspiration and Expiration, through some Obstruction, or compression of the Bronchia, &c. we properly call this a Difficulty of Breath: But if this difficulty be by the Constriction of the Bronchia, 'tis properly the periodic Asthma: And if the Constriction be great, it is with Wheezing; but if less, the Wheezing is not so evident; the Pulse being stopt in the Asthma Fit, the Respiration is Rare."

Then he described two forms of asthma:

1.  Continued:  Dyspnea was the result of other diseases such as dropsy, empyema, tubercles in the lungs, thoracic tumors, abdominal tumors, and spinal conditions such as scoliosis.  He used continued the way we use chronic, meaning that the condition is always present.  Chronic bronchitis and emphysema might also be categorized under this category if they were known diseases at the time.

Eighteenth century physician Michael Ryan quoted Floyer:

When the asthma continues for some months, it is a true pulmonic asthma, and depends on some disease in the breast, as dropsy, tubercle, absess, which compress the bronchia; and till that evident cause be removed, it is impossible to cure the asthma fits."  (3, page 8)

2.  Periodic:  This is bronchial constriction due to "windy spirits" occurring after fevers, catarrh (colds), and hypochondriacal fits (nerves) or as what he referred to as "flatulent slimey cacochymia, which is bred in the Stomach."

Floyer described his own asthma as periodic, and it is this type of asthma that covers the majority of his Treaties on Asthma.  Floyer noted that continued asthma is known to take the life of the asthmatic, yet most people with periodic asthma lived a normal life span.  However, periodic asthma did take a life from time to time.

A little less than 100 years later, Dr. Henry Hyde Salter would further refine Floyer's asthma definition using empirical knowledge known to him, and he referred to pure asthma as periodic in nature, and continued asthma as asthma associated with some type of organic changes, such as chronic bronchitis or enlarged heart.

Floyer became the first to describe seasonal asthma.  Floyer wrote how he kept a "diary of his disease, out of what I can give a more true Account than if I had now recollected what has long since passed."

He observed that he never had any problem with his asthma while he was at Oxford, yet when he returned to Staffordshire he...

...usually visited with a severe Fit or two.  The air of a Town makes the Fits more severe when they happen; but I do not think the Asthmatic so much expos'd to the Accident of the Weather in a City, as in the Country.

He noted that his asthma was worse in the summer than winter, and worse during "the change of the moon."

Barometric pressure can also affect asthma, he proposed, and that is why he recommended changes in weather as a probable cause of asthma.

So he may have been the first to notice the benefits of certain types of air in causing asthma, an idea Salter would later embellish upon.  Such observations may have lead to the later recommendation for asthmatics to move to other areas in order to treat and cure it.

He may also have been the first to describe how tobacco fumes from smoking cigarettes may trigger an asthma attack, yet his reasoning for this was quite supernatural:

"During the Fit of the Asthma, the Smoak of Tobacco is so offensive that it very much straitens the Breath, if it be smoaked the first Day of theFit, and much endangers a Suffocation. There are many Asthmatics that cannot bear the smell of it; therefore its Foetor is injurious any time, its Heat thickens the Phlegm and rerefies their aerial Spirits, making them restless; all the good it can do is to discuss the Windiness after the Fit abates, and to help the coughing up of Phlegm."

Floyer may have been among the first to note that very few people die of an asthma attack, and that between such attacks the asthmatic can live a relatively normal life.  He wrote:

"I have met with some Asthmatics who have been so for Fifty years, as they informed me, and yet in tolerable Health without any considerable Decay of their Lungs, or Disability to perform their usual Employments; which I oft reflect on to encourage my patients, and myself, who yet can study, walk, ride, and follow my Employment, eat, drink, and sleep, as well as ever I could; neither am I yet sensible of any Decay in my Lungs."

Alex Sakula noted that while Floyer's acceptance of Galanic principles would later be proven false, "his treatise shows that he was familiar with the multifactorial basis of asthma -- heredity, occupation, atmospheric pollution, hypersensitivity, infection, exercise, and psychological influences."

Because his theories about medicine were more readily accepted by society in the 17th century, Floyers is often given credit as the first to define asthma as a disease of it's own, more specifically as a disease of bronchospasm, even while this wasn't true.  Regardless, he did play a significant part in defining asthma.

Floyers would die on February 1, 1734, yet his teachings would be studied by physicians for the next hundred years, and his practice of measuring a pulse and respiratory rate became a common medical practice that is still used to this day.

Further reading:

1. Floyer's asthma symptoms, triggers and remedies by clicking here. 
2. Floyer establishes spasmotic theory of asthma (will be published 4/17/14)

Click here for more asthma history.

References:

1. Sakula, Alex "John Floyer:  A Treaties on Asthma," Thorax, 1984, 39: 248-254
2. Floyers, John, "A Treaties on Asthma," 1698, London, pages
3. Ryan, Michael, "Observations on the history of asthma, in which the propriety of using the cold bath in that disorder is fully considered," 1793, London, printed by G.G. J. and J. Robinson of Paternoster-Rowe

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