400 B.C.-1881: Steam inhalers

Stern's Inhaler (3)

Since the time of Hippocrates, and more than likely even before that, the inhalation of steam was often recommended for people suffering from various ailments, which included syphilis, asthma, bronchitis, pneumonia, hay fever, phthisis, croup, laryngitis, influenza, etc.  It was something that appeared to provide some immediate relief for difficult breathing.  

At some point in history it was determined that an additional benefit was supplied to the patient when certain medicines were added to the water to be inhaled.  

Initial steam powered inhalers were home made devises that resembled a tea pot, although by the 1870s various inexpensive and portable devices were available on the market for the inhalation of medicated vapors.

By traveling back in time we will find many different devices that were used as steam powered inhalers, some of these I covered in other posts.  Today, for your convenience, I am providing a list of all the various steam powered inhalers used over the years.

That in mind, here are some steam powered inhalers.

1.  Hippocratic Inhaler (400 B.C.):  It wasn't called an inhaler back then, and may not even have been used for asthma.  The model basically consisted of a jar with a hole in the lid. The steam itself may have been palliative, although adding certain balsamics or resinic substances may have added an additional benefit for various symptoms of lung disorders. Eggshells or a sponge may be placed between the patient's mouth and reed to prevent scolding.

2.  Teapot:  Any simple teapot would do.  Boil the water and inhale the steam.  If the water is too hot, you simply waited until it was cool enough to inhale.  This was kind of the same principle as the Hippocratic inhaler, which may even have lead to it's design.  Like the Hippocratic model, it was a simple and inexpensive inhaler. 

Inhalation Of Hot-water Vapor With The Use Of Pitcher And Towel

3.  Sponge:  Dr. John Scutter described dipping a sponge into boiling hot water, placing your face into the sponge, and inhaling. If the patient wanted he could drop some medications onto the sponge for direct inhalation.

This was an inexpensive and effective means of inhaling steam or medicated steam.  For medicines like chlorine, the medicine could be dipped on a cloth, placed over your face, and you could inhale the fumes that way. (2, page 22)

4.  Wine Bottle or jug:  Another simple method mentioned by Dr. Scutter was to simply place a wine bottle "partly filled  with hotwater" near your face and inhale the vapors as they pass from "the mouth of the bottle."

Another idea would be to insert a sponge into the bottom of a wide wine bottle and insert the water and medication onto the sponge.  The patient could use the sponge or wine bottle method, or a combination, and place a towel over your head for the full steam effect.

The patient could basically play around with these ideas until you found something that worked for you.  I remember my grandma turning on the hot water in the bathroom sink, having me set my head up close, and placing a towel over my head.  It never really worked, and there was no medicine involved, although it made her feel like she was helping. (2, page 22)

Dr. Mudge's Inhaler

5.  Phillip Stern's Contraption (1768):  It was a unique design, an advancement of sorts, on the Hippocratic inhaler.

Dr. Cohen said the lid was angled in a conic fashion so that it created a pointed mouthpiece whereby the patient placed his lips over the device, inhaled, and then took his mouth off to exhale.

Stern marketed it to be used with his own balsamic effluvium.  Half a pint of boiling water is to be inserted into the contraption, and about 30-40 drops of his balsamic effluvium (of which he does not divulge the ingredients).

The patients to whom he aimed his product at were consumptive and asthmatic patients.

6.  Dr. Mudge's Patented Inhaler (1778):  It's another design based on the Hippocratic model, and it was the first inhaler to allow both inhalation and exhalation through the inhaler.

Mudge was also the first to use the term "inhaler." Because Dr. Stern wasn't much respected by the medical community, Dr. Mudge is often given credit as the inventor of the inhaler.  (1, pages 18-20)


Flask inhaler (2)

4.  Flask inhaler:  Dr. Scutter said this inhaler could easily be made by any patient using random items around the household, or that could be easily purchased for a reasonable price at any general store.

Basically, all it required was a container that could hold heated water, and "a tube to conduct that vapor to the patient.  Fig. 1, represents such an instrument. The flask was made of flint glass, and will usually bear an elevated temperature. The cork was perforated by an opening for the attachment of the rubber tube, and for a smaller glass or metal tube for the admission of atmospheric air, as the patient inhales the vapor," said Cohen. (2, page 28-9)

5.  Tin Cup Inhaler.  Another cheap method of making an inhaler (see figure 2). 

Dr. Scutter said he often recommended this in place of the (much preferred) Nelson Inhaler (see below). 

In the words of Scutter: 

Tin cup inhaler (

"It consists of a tin cup, perforated at the bottom and a three quarter inch tube inserted and soldered. To this, is attached two or three feet of rubber tubing, which is terminated by a mouth and nosepiece as represented in the wood cut. The cup contains two cross wires to hold the sponge, which should be coarse and open. In using this apparatus, the sponge is pressed out of hot water and put in the cup, or it may be wet in the cup, and the medicine then sprinkled on it in suficient quantity. The cup being placed upon the floor, a chair, or, if more heat is required, upon the stove, the patient inhales the vapors as they arise. In country practice, it is well to have the cup made the size of a tea-kettle, or tin teapot lid, so they can be turned over these vessels if it is desirable to inhale the vapor of water. This apparatus recommends itself, in that it is simple, cleanly, and cheap, being easily manufactured wherever a tinner can be found, at a cost of 75 cents." (2, pages 29-30)

So it was easily made and cheap.

Wolfe-Bottle Inhaler (1)

6.  Wolfe-Bottle Inhaler: Cohen described this inhaler as...

"An efficient inhaler in common use is composed of a three-necked Wolfe's bottle (Fig. 2). Two of the corks are perforated. Through one an air-tube passes nearly to the bottom of the vessel; through the other the inhaling-tube passes a short distance. When in use, the bottle being partially filled with liquid, the external air passes through the straight tube into the liquid, and then out of the bent tube, to which tubing and mouthpiece may be attached. A wide-mouthed bottle, with a doubly-perforated cork (Fig. 3), answers the same purpose, and can be arranged extemporaneously at short notice. The bottles should be of the capacity of a quart, and the tubes of large calibre, so that respiration may take place with as little impediment as may be. The great defect in most modern inhalers is that the tubes are insufficient in calibre for the air to be drawn through them by mere aspiration, so that an accessory movement of suction becomes requisite." (1, page 21)

So this was another simple inhaler.

Mackenzie's Eclectic Inhaler (1) (5, page 64)

7. Morell Mackenzie's Eclectic Inhaler:  It was one of the most "complete instruments of it's kind," said Cohen. 

It was made of porcelain, and basically consisted of three parts:  A stand that was hollowed out so it could hold a heated lamp (c), a vase filled with a quart of hot water and medicine (a), and a lid that had two openings. (1, page 24)

One of the openings on the lid consisted of a pipe to allow free flow of air so te patient could breathe through the inhaler.  The other opening was attached a hose allowing the patient to inhale the steam.  (1, page 24)


Mandl Inhaler (1)

8.  Mandl's Inhaler or Fumigator:  This was a smaller version of the eclectic inhaler with some advancements. 

The lamp was inserted to the bottom of the vessel to gain better control of the temperature of the water. 

Cohen said there were a variety of inhalers of this type, but this one was the best.

The reservoir or vessel was made of glass that "rests on a stand over the spirit lamp.  The inspired air as it passes over the vapor becomes impregnated with it, and the expired air escapes by the opening of entrance. The vapor being evolved by heat there is no necessity for an air-tube to dip into the fluid. The amount of heat necessary to evolve the vapor is regulated by altering the size of the wick, or by the occasional removal of the lamp." (1, page 24-26)

Cohen must have been impressed enough with this inhaler that he made it the feature inhaler on the cover of his book. (1, page 25-26)


The Nelson Inhaler: This was by far the best of all the steam powered inhalers, and is actually still available.

The most marketable aspect of this inhaler is it allows the patient to inhale steam, or medicated steam, through a device that is portable. 

Nelson Inhale9.  

As you can see by the picture, it's quite small and compact compared to the devices mentioned above.  It's also easy to use by following the simple directions inked on the back:  "Remove the corked stopper, and fill the vessel half full of hot water; then pour the remedy to be employed upon the sponge on the mouthpiece. Place lips on mouthpiece. Breathe easily in and out as in full respiration. When only the vapor of hot water or any infusion is desired, remove the sponge from mouthpiece."

The Nelson Inhaler was one of the most common inhalers.  Due to its simple design and ease of use it was also the most copied design.

10. Maw's Double Valved Earthenware Inhaler:  It was similar in design to the Nelson Inhaler and sold by the same distributor: S. Maw, Son, and Thomson.  An ad in the December 24, 1870, edition of the British Medical Journal advertised this inhaler, along with the Eclectic Inhaler and the Nelson inhaler.

Here is what this ad said about the Earthenware Inhaler:

"For the inhalation of vapour of Hot Water, either alone or impregnated with Ether, Chloriform, Henbane, Creosote, Vinegar, etc, in affections of the throat and bronchial tubes, Asthma, Consumption, etc. For this apparatus, is especially adapted for Chloriform, Ether and other active volatile substances, as from its construction the exact quantity required may be inhaled. The lower valve opens only during inhalation, whilest the exhaled breath passes freely from the upper valve, instead of through the vessel, dissipating a large portion of the medicated vapour, as is the case in the use of most other inhalers. (6)

It was yet another inexpensive and easy to use option.

A. The inhaler with woolen cover
C. The inhaler without the woolen cover
B. The upper part disconnected from the inhaler1

It also came with a woolen cover to keep the temperature of the fluid contained in it from dropping too fast, and to prevent the person handling it from getting burned. (5, pages 68-69)

A thermometer came with the device, and when not in use it could be stored inside the apparatus.  (5, pages 68-69)

When the inhaler was needed (see figure), the thermometer was inserted through a hole in the lid.  Hot water was poured into the device (f) to just below the holes in the side of it (c).  (5, pages 68-69)

11. Martindale's Portable Inhaler: It was similar to the Eclectic Inhaler of Dr. Mackenzie, although it was made of tin, which made it more portable and less costly. (5, pages 68-69)

As the patient inhaled through the mouthpiece, air is drawn into the fluid through the holes (c), becomes medicated as it passes through the fluid, and is inhaled.  As the air goes through the holes it makes a gurgling sound. The exertion required by the patient is minimal, and using the apparatus is very easy.  (5, pages 68-69)

Bullock's Hospital Inhaler.
Left: The inhaler with mouthpiece
Right: The lid with India-rubber nasal dilator

12.  Bullock's Hospital inhaler:  It's a strong stoneware jug covered with a metal lid.  An India-rubber band holds the lid to the jug.  There are two holes in the metal lid.  In one hole is inserted a tube with mouthpiece used to inhale medicated steam.  Into the other hold was the thermometer to measure the temperature of the fluid to make sure it was not too cool and not too hot.  It could also be used for nasal inhalations by removing the tube and mouthpiece and adding an India-rubber nasal dilator.  Directions on how to use the inhaler came with it.  (5, pages 67-68)

How much medicine, if any, was usually directed by a physician. The 1881 "Pharmacopoeia of the Hospital for Diseases of the Throat and Chest" edited by Morell Mackenzie suggested that most of the devices described above required about a pint of water with about a teaspoon of the medicine, which is made according to specific recipes.  The dose may be increased or decreased slightly for desired effect.  (5, page 69) 

As noted, there were many variations of all these inhalers, many of which can be found in the various medical books and magazines from the 18th and 19th centuries.  

Note:  There were other inhalers that were steam powered, such as the Siegle Inhaler and Adams Inhaler. However, the inhalers described above allow the patient to inhale a medicated steam, while the Siegle and Adams Inhalers use steam to allow the patient to inhale a mist.  It should be noted there is a difference, as mist inhalers allow a patient to inhale both volatile and non-volatile solutions, while steam inhalers only allow for the use of volatile solutions. 

References:

1. Cohen, Jacob Solis, "Inhalation in the treatment of disease: it's therapeutics and practice," 1876, Philadelphia, Lindsay and Blakiston
2. Scudder, John Milton, " On the use of medicated Inhalations in the treatment of diseases of the respiratory organs," 1867, Cincinnati, 2nd edition, Moor, Wilstach, and Baldwin
3. Sander, Mark, "Inhalatorium.com,"  page 41, http://inhalatorium.com/page41.html, accessed on 9/27/12.  Photo used by permission from Mark Sanders. 
4. Tissier,Paul Lewis Alexandre, edited by Solomon Solis Cohen, "Pneumotherapy: Including Aerotherapy and inhalation methods," volume X, 1903, Philadelphia, P. Blakiston's Sons and Co., pages 353-
5. Mackenzie, Morell, editor, "The Pharmacopoeia of the Hospital for Diseases of the Throat and Chest," 4th edition, 1881, Philadelphia, Plesley Blakiston
6. Hart, Ernest, editor, "Maw's double valved earthenware inhaler," British Medical Journal, The Journal of the British Medical Association, volume II, July-December, 1870, (December 24, page 672 of this publication)

RT Cave Facebook Page
RT Cave on Twitter

100 A.D.: Pipes made inhaling herbal remedies easy

Figure 4 --Ad for Schiffmann's Asthma Cure (1899) (3)

Again, it's impossible to know who carved out, let alone smoked, the first pipes.  It's also impossible to know for whom the first pipe was carved for, nor what herbs were stuffed inside them.

It's possible the idea of using a sharp tool to hollow out a piece of wood for smoking herbs may have occurred to various inventors in various societies at different times.  The component smoked depended on what herbs were available.

For example, in India the incentive to carve out pipes was to smoke strammonium, belladonna, or Indian hemp for it's hallucinogenic effect. The fact the herb had other medicinal properties may have been learned later, or earlier.  Who knows?

Either way, inhaling smoke directly from a pipe would have allowed direct inhalation of the smoke, resulting in a greater effect. It would also have improved convenience, meaning that herbs could be smoked anywhere and anytime.

What we know for sure is the first medicinal use of pipes to smoke a medicine for asthma-like symptoms was recorded in ancient India around 100 A.D.  There were many herbs the Indians had access to, and one such was datura strammonium. (1)

The herb produces an unpleasant smell and grows to be about five feet tall with a pale green stem with spreading branches and puplish leaves coarsely sedated along the edges.  Its flowers are white or purple.  (1)

By empirical means its entertaining effect was learned, as well as its poisonous qualities when too much was inhaled or ingested, which mainly included hallucinogenic effects.  At times it must have been observed the medicine made you mad, which may explain the name.

Datura comes from the ancient Hindu word for plant, dhatura.  Stramonium is a New Latin word meaning thornapple.  Strammonium originally came from the Greek word strychnos which means nighshade and mankos meaning "mad."  (2)

Other than thornapple, common names I've found during my research that refer to strammonium are jimsonweed, Jamestown weed, drowny thornapple, Devil's trumpet, angel's trumpet, mad apple, stink weed and tolguacha.  It was obvious by these names the side effects of inhaling too much was well known

Like belladonna, the leaves, stems and roots were dried and crushed into a fine powder the Indians stuffed into their pipes and smoked it.  The benefits obtained must have been of higher quality than simply inhaling fumes from igniting the herbs on bricks.  Although either technique may have been used, depending on what the patient had access to.

Obviously the herb may have been used for entertainment, although medicine men and physicians ultimately learned of the medicinal benefits.  By 100 A.D. Indian physicians recommended smoking  strammonium for diseases of the lungs and throat, or simply for its hallucinogenic effect.  Again, the hallucinogenic effect may be desired when no other remedy was applicable

The famous Greek physician Hippocrates wrote about stramonium and belladonna, so we know Greek physicians had access to such wisdom.  With the fall of Cordova Greek medicine made its way to Rome, so we know the Romans had access to it too.   With the fall of Rome all such knowledge was lost for over a thousand years in Europe. 

Although, shortly thereafter, all medical wisdom made its way to the Arabia, where medicine, including including the inhalation of herbs, was saved for mankind. 

References:

1. "Plants poisonous to livestock," Cornell University's Department of Animal Science,  http://www.ansci.cornell.edu/plants/jimsonweed/jimsonweed.html
2. "Plants poisonous to livestock," ibid
3. Picture used with permission from Inhalatorium.comJackson, Mark, "'Divine Stramonium': The Rise and Fall of Smoking for Asthma,"  Med Hist., 2010 April; 54(2): 171–194.
4. Jackson, Mark, "'Divine Stramonium': The Rise and Fall of Smoking for Asthma," Med Hist., 2010 April; 54(2): 171–194.

RT Cave Facebook Page

RT Cave on Twitter

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

120-200 A.D. Galen wonders what causes asthma

Galen saw that some of his patients presented with a symptom described by Hippocrates as asthma, and he saw this malady in his own patients.  By placing his ear to their chests he heard their wheezes.  He thus set off on a relentless quest to find the natural cause of asthma and remedies to cure it.

He relentlessly questioned and assessed his asthmatic patients. He would have loved to have dissected those who died of the malady, but such an act was forbidden under sentence of death and punishment by the gods.

Now, that said, it's also possible that Galen, or perhaps one of his assistants, stole a body or two from a local cemetery to surreptitiously dissect.  This may have been how came so close to discovering that blood circulates rather than moves in a to and fro motion inside the body.

Still, even if he did have a few opportunities to dissect humans, it was rare, mainly because if he was caught it would come at an extreme cost to his reputation.

So, instead, he mostly cut into apes, pigs and monkeys.  He cut open their chests and observed their lungs. He cut into the lungs and traced the air passages.  He concluded this was where the vital force of life, the pneuma, enters the body.

He traced vessels from the lungs to the brain.  Perhaps this confirmed his assumption, one Hippocrates had alluded to, that asthma was similar to epilepsy. Like epilepsy, asthma displayed no symptoms between attacks (sporadic), and left no observable traces of disease.

He believed epilepsy was caused by an increased abundance of phlegm in the brain, and this caused seizures. So he concluded asthma was caused by an increased abundance of phlegm in the lungs, and this caused difficulty breathing by blocked air passages.

He also noted a second cause of asthma, and this was tubercles in the lungs.  (13, page 1)

In one experiment he severed the medulla spinalis and artificially produced asthma.  He used this experiment to prove to his pupils that asthma could be produced artificially.  Perhaps later physicians used this experiment as proof that asthma was nervous in origin.  (13, page 1)

Asthma historian Mark Jackson said that on Galen's experience he wrote that "if the breathing is rough and noisy it indicates that a large amount of thick and sticky humors in the bronchial tubes of the lungs has accumulated and become annoying because it is difficult to expectorate." (4, page 24)

In this way he is credited by history as being the first to link asthma to the air passages of the lungs, and the first to describe asthma as a disease of obstructed airways.

As noted, remedies by Galen were meant to restore the balance of the elements and humors. If you sought him out to cure your asthma, he'd probably first recommend a bath, a good diet, and exercise.  Once these simple remedies were attempted and failed, only then would he dip into his stock of medicine.

In 1815, Thomas Young said that general remedies prescribed by Galen were copied from the likes of Asclepiades, Musa, Andromachus, Heron, Crito, Menecrates, Archigenes, and Phillipus.  Galen mentioned a treatment borrowed from Asclepiades for orthopnia, a common symptoms of asthma, that contained mellepedes, which were supposed to have a diuretic effect (makes you pee).  (5, page 145)

Arabic historian Paulus Aegineta said that for asthma Galen prescribed the following (in parenthesis is what modern experts believe would be the effect of the remedy): (6, page 407)

1. Squill (alleviates coughing)
2. Pepper (stimulates digestive system)
3. Wormwood (stimulates digestive system)
4. Opoponax (antispasmotic, respiratory decongestant)
5. Storax (expectorant)
6. Oxymel (expectorant)
7. Sulfer (eases allergy symptoms such as sore throat and cough)
8. Millepedes (diuretic)(6, page 407)

Jackson said he made about 70 references to asthma, sometimes as the symptom of rapid breathing described by Homer and Hippocrates, and sometimes as a disease that caused breathing difficulties.  (4, page 24)

In 1851, Joseph Bergson said that Galen may even have been among the first to suspect that asthma was nervous in origin.  He wrote:

Galen, who made sections of the spinal marrow in different places in living animals, in order to demonstrate to his pupils the influence of it on motions of respiration. (12, page 374)

The theories he postulated about asthma, as with all his medical theories, influenced the world for the next 1,800 year. Slowly, through the course of time, a few brave physicians would expound upon his ideas about asthma, and by this means the definition would mature.

References:  see the post "120-200 A.D.: Galen becomes world's greatest physician"

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

RT Cave Facebook Page
RT Cave on Twitter

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

RT Cave Facebook Page
RT Cave on Twitter