AD 32-79: Pliny the elder's contribution to asthma

Pliney the Elder (23-79 A.D.)

Gaius Plinius Secondus, better known as Pliney the Elder,  was a Roman admiral, an encyclopedist, and an asthmatic who mentioned asthma-like symptoms in his book, "Natural History.".

Russell M. Lawson, in his book "Science in the Ancient World: An Encyclopedia," wrote that Pliny was born in 23 A.D. during the reign of Rome's second emperor Tiberius.  He was of the equestrian class, of whom the emporers relied upon for political support and to fill the many administrative positions. (1)

He served in the military as a provincial governor, and was head of the Roman fleet, a position he held at his death when mount Vesuvius erupted and he supposedly died of either asthma or heart complications in 79 A.D after he tried to help those who were trying to flee the volcano.  (2)

I think it was interesting to learn from Lawson that Pliney was a Stoic, which meant that he believed there was no after life, and this life was all a person had.  Thus, perhaps for this reason, he slept little and spent most of his time writing.  He wrote other books, but his most famous was Natural History. 

Lawson explained that Natural History is a "diverse collection of anecdotes, history, geography, medical information of varying worth, discussions of astronomy and earth science, and a catalog of Roman knowledge of botany and zoology." (3)

Russell further explained that because the book was filled with "interesting information and useful facts it became one of the most widely read books during the Late Roman Empire, Middle Ages, and Renaissance." (4)

Likewise, Russel writes, Pliney based many of his studies on the writings of other physicians and scientists along with his own experiences, and when he recorded the observation of other writers such as Herodotus, Polybius or Alexander the Great, Pliney's descriptions were often better than that of the original authors. (5)

He mentions asthma-like symptoms in his book, yet he preferred to use Latin terms to describe dyspnea, shortness of breath instead of asthma. (6) Pliney wrote once that Rome had gone 600 years without physicians so why do we need them now.  He wrote this in reference to Rome adapting Greek medical terms and Greek methods of diagnosing and treating patients. 

Remedies he prescribed for asthma to "facilitate the respiration":

1. Blood of wild horses taken in drink
2. Asse's mild boiled with bulbs
3. The liver or lights of a fox in red wine
4. Bear's gall in water
5. Oil of balsamum
6. Rue combined with bitumen
7. Pitched wines unless there was also a fever involved
8. Blood of wild horse taken in drink  (7)
9. Chrysochola combined with honey is good for sore throats and asthma (8)
10. Snails:  Good for a cough and stomach ache, and a cure for asthma, fever, etc. (9)
11. Vinegar (10)

Many of the magical cures, superstitions, remedies for physical illnesses described in Natural History were followed and used for over 2,000 years.

Pliney the Elder was a classic recorder and cataloger of events that occurred in his day, but he was also great at recording things he learned from others, either fact or hearsay, and likewise the wisdom of other great discoverers, writers, and explorers who lived before him.

It is for this reason he is described as encyclopedic, and, as Lawson explained, one of the main reasons students of the ancient world "know of ancient writers and writings that would otherwise be unknown, save for Pliney's eforts."

Click here for more asthma history.

References:  

1. Lawson, Russell M., "Science in the Ancient World: An Encyclopedia," 2004, California, pages 190-192
2. Lawson, ibid
3. Lawson, ibid
4. Lawson, ibid
5. Lawson, ibid
6. Jackson, Mark, "Asthma: A Biography," 2006, New York, page 17
7. Pliny the Elder, "The Natural Hisotry or Pliny," translated by John Bostock and H.T. Riley, Vol. V., 1856, London, page 344
8. Bostock, John, "The first and thirty-third books of Pliny's Natural History; a specimin or proposed translation of the whole work with notes and etc," 1928, London, page 47
9. Harmer, S.F. (editor), "The Cambridge Natural History," Volume III, 1895, Norwood, Massachusettes, page 120
10. Lawson, Russell, ibid, page 190-192

1600s: The first specific description of asthma

So the term asthma was first appeared in Ancient Greece in the writings of Homer, and was defined as a medical term by Hippocrates.  In Ancient Rome it was used sparingly, and it didn't find its way into English and other European languages until about 1398.

Medical wisdom in Western societies societies hit a wall of sorts with the fall of the once mighty Roman Empire, only to rise up in Eastern socieites.  Around the 900s, 1000s, and 1100s such wisdom started to filter back West, yet it was a slow transition to say the least.

With the fall of Constantinople in 1453 the dark ages ended and the age of Reniassance began.  Old Western ideas about medicine and science started to re-emerge, and new ideas started to form.  The first Western physician during this era to take a look at the term asthma was Jean Baptiste van Helmont.

Even during modern times physicians and scientists who become rapt in a certain disease are usually those who are affected by it, and van Helmont was no exception.  He was afflicted with asthma from a young age, and he became especially interested in it as a physician.

He was the first to describe asthma as anything other than simply a symptom.  He was the first to propose the idea that asthma was a disease of bronchospasm when he wrote:  "The lungs are contracted or drawn together."  Galen mentioned something of the sort, yet it was van Helmont who focused attention on the subject.

Van Helmont was also the first to describe asthma as a nervous disorder. Thomas Willis is given credit for the nervous theory of asthma more so than anyone, yet that's only because Willis wrote more specifically about it than van Helmont.  So we will give due credit where credit is due.

English physician John Floyer, who also had asthma, worked to distinguish asthma from other disorders.  According to the American Journal of Respiratory Cell and Molecular Biology, "A Centennial History of Research on Asthma Pathogenesis," written by Michael J. Walter and Michael J. Holtzman: 

"Dr. Floyer, who developed asthma following a respiratory infection,provided detailed accounts of the asthma signs and symptoms, treatment, prevention, and prognosis. He also also described a hereditary component of asthma, and numerous exacerbating factors such as air pollution, infection, cold air, exercise, sleep, psychological stress, and tobacco smoke, and astutely observed the benefits of clean air and environmental change."

Still, the bronchoconstriction theory of asthma was debated through the 19th century as we will discuss soon on this blog. The nervous theory likewise gained major acceptance until it was finally shot down in the 1950s.  In fact, one of the main reasons the bronchospasm theory of asthma originally proposed by van Helmont and Floyer was because of their belief in the nervous theory of asthma.

However, in their defense, asthma was often described as a nervous disorder even by the ancients, especially once it was learned that asthma left no scars in the lungs.  Since there were no scars asthma must be nervous in origin.


Asthmatics tended to be looked at as weak and inferior in most civilizations. They weren't able to go off to war, weren't able to ride horses, weren't able to sleep with pigs, and tended to spend more time socializing with women than hunting with the men.

Still, the 17th century provided a dawn of sorts for asthma wisdom.  Thanks to the works of van Helmont and Floyer future asthma experts had a foundation to work from, however flawed it was.

One of the main reasons it was debated was due to the nervous theory of asthma.

Click here for more asthma history.

So the dark ages of medicine actually  began about 300 B.C., about the time Erasistratus was founding the great Egyptian School of Anatomy in Alexandria.  It was from this time until about 1600 A.D. that medicine -- for the Western world anyway -- was at a standstill.  

Actually,  according to a John Hopkins Hospital bulleton from 1904, "from the epoch of the Alexandria School (300 B.C.) to the School of Salerno (1224 B.C.), or more probably to the School of Mundino (1306), the human body had never been dissected."  (1)

In Ancient Greece and Rome dissecting a human was illegal on grounds of religious reasons, and during most of the dark ages it was viewed as morbid and disgusting.  People had more important things to do than dissect humans and apes, such as survive. 

Science was set aside in lue of faith, and pre-Hippocratic ideas that disease was caused by supernatural causes, or was the result of evil forces.  Treatment for diseases resorted back to primitive methods such as folk medicine and exorcism.

After Galen wrote his books in the second century there were little advancement in medicine, and this -- as we decided earlier, was one of the reasons Galen's works were worshiped as the Bible of medicine, as though Galen himself were a medical god.  

Jacobus Sylvius (1478-1555)

John Hudson Tiner, in his book "Exploring the History of Medicine," wrote about Jacobus Sylvius  (early 1500s), who was an professor at the University of Paris.  He would open up one of Galen's books and begin reading, and usually an animal was dissected to go along with the lecture.  Once a year Sylvius dissected a human.  While he read, an assistant did the cutting, and another pointed to each part of the body as the professor read aloud. (2)

"Often," Hudson writes, "what Sylvius reads Dan the assistant points to don't agree.  Sylvius steadfastly refuses to see any errors in Galen. Galen taught that the liver was five-lobed, that the breastbone had seven segments, that a network of blood vessels could be found under the brain.  Sylvius believes every word of it, although those features couldn't be found in the body right under his eyes.  He saw exactly what Galen told him he would see! (3)

"If the corpse and book don't agree, then the error is in the corpse!  No one would dream of doubting Galen."

Yet then along came Andreas Vesalius who was was born in 1514.  Hudson describes that he wasn't content to just believe everything Galen wrote.  Vesalius believed that the best teacher of the human body was not Galen but the human body.  He stole a skeleton and studied it.  He learned the human breastbone did not have eight segments as Galen described, it had only three parts.  How could a teacher as magnificent as Galen have gotten it wrong?

Andreas Vesalius (1514-1564)

Then by chance one day Vesalius had dissected an Ape.  Then it occurred to him:  Galen had never even dissected a human body, otherwise he would have known the human sternum has only three parts.  For thousands of years doctors had treated diseases based on the anatomy of apes not of humans.

Now, to Galen's defense I should note here that in both Ancient Greece and Ancient Rome it was illegal to dissect a human body.  In fact, it was illegal to even touch a corpse except for preparing it for burial.

Tiner notes that Vesalius became a professor in 1537 and decided to dissect the bodies himself. His colleagues wondered why he would waste his time considering Galen had described the human body so perfectly.  Learning from dissecting was a waste of time, and what was needed could be learned from Galen's books.

Despite the outcries by his fellow professors, Vesalius became popular.  Because his bodies decomposed quickly, he hired jan Stephen van Calcar to draw the human body, and he published the first accurate book of the human anatomy.  From this point on the human anatomy could be taught based on accurate pictures and descriptions, as opposed to Galen's ignorant descriptions.

I thought it was interesting that Tiney writes that artists like Michelangelo knew more about the human anatomy that doctors, because artists needed to have an accurate description of the body, they studied it up and down, so that they could accurately draw the body.  Doctors merely studied Galen.

So, Tiney writes, "Experts often date the start of the scientific revolution from the year, 1543."

Yet Vesalius's truths did not come without a fight from doctors stuck in the paradigm that Galen was right.  In fact, doctors even to this day often have a hard time breaking away from what they were taught in med schools, even though their old ideas are disproved by scientific evidence.

You can see it yet today with many doctors refusing to believe the Hypoxic Drive Theory is not true, or all that causes dyspnea and wheezes should be treated as asthma with bronchodilators.

So Vesalius's fellow doctors "fiercely" opposed Vesalius because they felt he was ruining their reputation.  They accused him of crimes.  They wrote books against Vesalius.  Instead of completing more medical work, he spent the next 20 years fighting to get others to recognize the importance of his book, "Fabric."

While his book is now recognized as one of the top ten most important medical discoveries of all time, Tiney never lived to see its acceptance into modern medicine.  His later travels took him out of Europe and nothing is known about when nor how he died.

Galen described that the liver manufactured new blood to replace the old, and even up until the 1600s physicians believed that veins carried blood away from the heart.  He believed that blood surging through the heart caused it to beat, according to Tiney.  He had no idea the heart itself pumped blood.

So, just like physicians believed Hippocrates's idea that disease is caused by an imbalance of the humors, and that bleeding is a cure for disease, physicians studied Galen's works even though much of it was simply wrong.

In 1602 a man named William Henry learned about valves in the veins from one of his instructors, and he wanted to learn what they are for.  He did experiments and later he proved that Galen was wrong, and that blood circulated the body.  The valves were to prevent slowly moving venous blood from backing up.

He described accurately how blood moves through the heart, and how the veins and arteries branch into smaller and smaller segments until they reach a particular organ or tissue.

Once again this new fact learned by Henry was not accepted in medical circles.  They couldn't imagine that Galen could be wrong, and they refused to accept that blood flowed in a circular pattern through the body.
Doctors proved him wrong by quoting Galen.

In 1661 another physician named Marcello Malpighi did experiments of his own on a frog and proved that Henry was correct.  He found microscopic vessels in the lungs that connected the arteries and the veins, and he called them capillaries.

Henry lived to be 80, just long enough to see his discovery accepted in the medical community.  Once again Galen was proven wrong, and once again a medical fallacy was proven wrong by science, and once again the task of proving science turned into a complicated task.

Like Vesalius's discoveries before him, Henry's discovery is considered one of the top ten medical discoveries of all time.  And it's discoveries like this that have helped medicine advance, whereby medical fallacies work only to slow the progress of medicine.

Thus, physicians of today ought to heed the lessons of the past and not shun modern wisdom, instead they ought to embrace it with open arms, or at least an open mind.

Click here for more asthma history.

References:

1. The John Hopkins Hospital bulleton," (volume XV 1904), "from the epoch of the Alexandria School (300 B.C.)"
2. Tiner, John Hudson, "Exploring the History of Medicine," _______, page
3. Tiner, ibid, page

100 A.D.: Aretaeus of Cappadoci accurately describes asthma

Somewhere around 100 A.D. lived an ancient Greek master clinician named Areteus of Cappadocia who was responsible for our first clear medical descriptions of many diseases such as pleurisy, diptheria, tetanus, pneumonia, diabetes, epilepsy and asthma. (1)

When he was born and when he died is unknown, although it's believed he lived somewhere around the first through the third century AD.  It's also unknown where he lived, although some think it may have been in one of the Eastern Roman provinces.  All we know of him is what he left in print.

However, like Hippocrates, it's believed he learned about medicine from physicians in Alexandria, Egypt.  Alexandria at that time was a major center of medical wisdom mainly because it was legal to dissect the human body in Egypt and not in Rome or Greece. 

He is of historical significance because he created a revival of sorts of Hippocratic medicine where diseases were caused by an imbalance of the four humors:  blood, phlegm, black bile and yellow bile.  After Hippocrates there were few advances in medicine until Aretaeus.

About 50 AD  Athenaeus of Attaleia established the Pneumatic School of Medicine, which is an advancement of sorts of the Hippocratic belief in the four humors.

Aretaeus he is considered to be a member of the Pneumatic School of Medicine, which believes that health was maintained by the balance pneuma, or "vital air."  (2)

Aeraeus 

Pneumatists believed that disturbances in the four humors, or an excess or deficiency in any one, will disturb the pneuma of that person, and cause medical problems. One of the main ways to determine if the pneuma is disturbed was by checking a patient's pulse to see if it is high.

Thus, this is why Hippocrates often made a pulse check one of his first assessments of his patients, along with asking a series of questions to learn about the patient's medical history.  Areteaus, like Hippocrates, believed there was a clinical reason for diseases, and simply singing a chant or blessing the patient would not remedy the problem.

Areteaus is known to have revived the Hippocratic way of doctoring patients, as he had a good technique and had a good bedside manner.  He was also a great communicator and writer.

He also believed in the following (according to bookrags.com:

• Blood is formed in the liver from food
• Phlegm is secreted from the brain to other organs
• Yellow bile comes from the liver
• Black bile comes from the spleen
• The most important organ is the heart, since it's the site of heat and pneuma
• The heart draws pneuma from the lungs, which is stimulated by it
• The spinal cord was an expansion of the brain, so all neurons began in the brain
• Respirations are a result of expansion and contraction of the lungs, involving the thorax and diaphragm

According to  encyclopedia.farlex.com his writings were lost until "1554 when two of his manuscripts, written in the Ionian dialect, On the Causes and Indications of Acute and Chronic Diseases, and On the Treatment of Acute and Chronic Diseases, were discovered and translated into Greek, Latin, French, Italian, and English."

Five of his works remain lost, along with several pages in the remaining books. 

In his book, Translation Areteus,  (written about 1785), John Moffat reprints many of the lost writings of Aretaeus, who provides the first really clear description of asthma.

Here is how Aretaeus described asthma way back in the first century AD:

"If a difficulty of breathing is produced either from running, excessive exercise, or any other cause, it is denominated asthma, or any other cause, it is denominated asthma: that disease likwise known by the name orthopnea, is called asthma, because the patients during the paroxysms are affected with difficulty of breathing, it obtains the appelation orthopnea from the patients not being able to breathe easily, unless in an erect posture of body, in a reclining state, there is danger of suffocation taking place." 

That's a pretty accurate description of what we would group as respiratory disorders and respiratory failure more so than just asthma. Yet back then the definition of asthma was pretty much all that causes short of breath, with dyspnea being mild asthma, and orthopnea being asthma while lying down.

He describes that asthma can lead to death: "should the heart suffer, death must inevitably be the consequence, as both respiration and life originate from this viscus."

Interestingly, he writes that the cause of asthma was "coldness of breath with moisture: the matter consists of thick gutinous humors lurking internally." This in interesting because he later describes how those suffering from asthma often year to get outdoors, or to search for cooler air.

This makes sense to me because as a hardluck asthmatic as a kid there were many times opened my bedroom window to get the fresh, cool outdoor air. As an RT I later learned it's common for those suffering from breathing trouble to yearn for cool, fresh air. Many chronic lung patients also have air conditioners cranked, windows open, fans on.

I think this is neat because Aretaeus of Cappadoci made this observation nearly 2000 years ago.

More accurately, when he is describing asthma as "a coldness and humidity of the spirit," he's probably referring to the pneuma, as he adds:  "But the materiel is a thick and viscit humour."

He writes that the disease is more likely to strike boys and women (because they are colder than men) more so than men, yet boys are more likely to recover because they an "increase in strength." Yet he writes if men get it it generally "sooner proves mortal."

He writes that death "strikes those slowly whose lungs are warmed from any workmanship" that warms the body. I believe here he's referring to things made by the following trades that warm the body that might remedy asthma:

• Manufacturing of wool (wrapping the asthmatic in warm blankets)
• Working with calx  (blacksmiths)
• Working with brass 
• Working with Iron (blacksmiths)
• Formenting of bath fires (people who heated bath houses, probably due to hot steam)

He describes the signs of early asthma:

• Heviness at the breast
• Slowness to perform usual business and everything else
• Difficulty of respiration both in running and walking
• Hoarseness and coughing
• Flatulency in the pracordia
• Eructations without being able to assign any reason (any symptom you don't know what it is is probably asthma)
• Watchfulness
• Small obscure nocturnal heat (probably creates the desire to find cool air)
• Nostrils are sharp and prepared for respiration

He likewise describes the signs of severe asthma (if the disease increases):

• The skin is pale
• Except the face, which is red
• Eyes stand out as in persons that are strangled
• Snore while awake (early description of wheezing?)
• The evils become worse at time of sleep
• Voice of obscure
• The desire to find cold air is great
• They walk around -- the house does not suffice
• Breathe in an erect posture as if anxious to draw in all the air possible
• They open their mouths greedily
• Profuse sweak breaks out about forehead and necck
• Constant violent cough
• Reject a small, thin, cold matter, somewhat resembling an efforescence of froth (I believe he is describing sputum here, which may be due to increased mucus production or pink froth from heart failure)
• The neck becomes tumid on drawing the breaths (paradoxical breathing?)
• The praecordia are revulsed
• Pulse is small, frequent, and oppressed
• Legs are wafted

End stage asthma (if the symptoms still increase):

• Patient becomes strangled as in the case of epilepsy

If the asthma reverses (a more favorable appearance):

• The cough is rarified
• Coughign becomes longer (more continuous?)
• Excretion of humid matter in greater quantity (increased sputum)
• Watery substance will be dejected in abundance
• Urine will flow copiously with sediment
• Voice will be better formed and more sonorous
• Attending with refreshing sleep (probably from exhaustion)
• Remission of the praecordia
• Pain during remission  in scapula (chest pain due to overworking accessory muscles?)
• Breathing becomes rare and gentle, (normal respirations, respirations slow back down)
• Degree of asperity of voice

He writes that "in this manner do the patients escape death, but during the remissions, although they walk about in an erect posture, they have evident symptoms of disease."

Aretaeus also describes a condition called he refers to as 'pneumodes.  In this case, "dyspnea, cough, insomnolency, and heat are common symptom, as also loss of appetite and general emaciation.  Sufferers of this condition usually die within a year.  This condition probably wasn't asthma as we know it today, but some other unknown respiratory ailment.

There you have it.  The above was the very first, accurate description of breathing trouble and respiratory falure.  As you read the above you'll see some signs of asthma, and some signs that aren't so much asthma but dyspnea caused by other ailments.

Click here for more asthma history.

References:

1. "Aretaeus of Cappadocia," The Free Dictionary by Farlex, http://encyclopedia.farlex.com/Aretaeus
2. "Aretaeus of Cappadocia," Encyclopedia Britannica, http://www.britannica.com/EBchecked/topic/33531/Aretaeus-Of-Cappadocia