1316: Mundinus publishes book of anatomy

So we know that the School of Salerno was a great medical institution from the 10th to 13th centuries, and physicians from all over the world flocked there to get the best medical instruction.  Yet most historians will acknowledge that while it was a great learning place, there were few medical advancements made here. 

One of the great exceptions occured in 1316 when Mundinus of Bologna (1270-1326) wrote a book called "Anathomia."  Although while he wrote it while teaching at Salerno, it was first published at Padua in 1487, and later at Leipzig in 1493 by Martin Pollich-von Mellerstadt. (see figure 1) (1, page 150-151)

Figure 1 --The title page of Mundinus
 "Anathomia," Leipzig, 1493 (1, page 151)

According to Fielding Hudson Garrison in his 1921 book, "An introduction to the history of medicine," "In intention, this book was really a little horn-book of dissecting, rather than a formal treaties on gross anatomy.  (1)

Garrison explains the book was full of "Galanic errors in regard to the structure of the human frame, preserving the old fictive anatomy of the Arabists, with the Arabic terms, this book was yet the sole textbook on anatomy for over a hundred years in all the Medieval schools." (1)

It was people like Mundinus who helped advance medicine through an otherwise dark ages of medicine in the western world.  Surely this was a small achievement, and there may have been no major advancements in asthma and respiratory therapy wisdom as a direct result of this.  Yet had it not been for such small achievements, asthma wisdom would still be in the dark ages, and chronic lungers would continue to be forced to suffer as a result.  

References:

1. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1922, Philadelphia, W.B. Saunders Company
2. The John Hopkins Hospital bulleton," (volume XV 1904), "from the epoch of the Alexandria School (300 B.C.)"
3. "The Ancient Medical School of Salerno," associazioneermes.it, http://www.associazioneermes.it/MedicalSchoolSalerno.htm, accessed 12/4/12

1970-1985: No antihistamines for asthmatic boys

As I look back on my asthma past, which I've done a lot lately considering I'm writing a history of asthma, the thing that irritates me the most is that I wasn't allowed to take anything for my allergies.  I had severe allergies, and I was forced to sufferer through every one of them.

The reason this irritates me so much is there were antihistamines available since the 1950s, and there were even antihistamines in the bathroom cabinet at our house, yet I wasn't allowed to take them.  Now I don't know if it was my mom's fault or my doctors, but the reason my mom gave me was because the box states not to use if you have asthma as it "may cause wheezing."

I have severe allergies.  I'm allergic to a variety of molds, dust, fungus, and you name it.  Today I know that when my allergy symptoms are controlled, so controlled is my asthma.  The thing it when you're an adult it's easier to stay away from your allergens.  It's still no fun to avoid them, yet it's possible  

Kids, on the other hand, are under constant pressure of their siblings and friends to play on the ground, the dirt, the woods, etc.  Kids are closer to the ground, where allergens hang out.  Kids roll on the carpet.  Kids play in the basement.  Kids play in old, dusty, worn out forts.  Kids play hide and seek in bushes.  Kids are all over.  It's just what kids do.  

So you can see how it would be hard for a kid to avoid allergens.  As a kid who tried to be as normal as possible, I usually did whatever my brothers and friends wanted to do.  I paid little attention to my allergies, and I usually suffered as a result (although this changed as I got older).  And, when the sniffling and sneezing came about, I was forced to suffer.  When I got older I'd sometimes request a medicine for it.  Yet I was allowed none of it.  I was forced to suffer (My parents had empathy, they just weren't allowed to use antihistamines for me).  

I remember more than once playing with my brothers, and all of a sudden my eye would be swollen shut.  My mom would have me sit in my room, or on the couch, for hours with a hot, washcloth over my eye.  I remember this would happen often while on vacation. If my asthma acted up, that was an added dilemma.  Yet my allergies were something that there was nothing I was allowed except avoidance and warm wash cloths, and sitting like a moron on the couch while everyone else was having fun.  At school I got picked on.

Benadryl was a medicine in the bathroom medicine cabinet also that was marketed as a cure for allergies.  It was available as a prescription since 1946.  But I wasn't allowed to use it.  Perhaps the reason for this goes back to 1949, 21 years before I was born, when the Food and Drug Administration (FDA) cleared Neohetamine as the first antihistamine for sale over the counter without a prescription.  This medicine and a variety of others, including Benadryl, were advertised in magazines all over the U.S. as a remedy for allergies and colds that could be purchased without a prescription.  (1, page 227)

By 1950 there were over 21 over the counter antihistamine products, "packaged under one hundred different trade names in tablets, nasal sprays, eye drops, and creams."  (1, page 216-17) and they were advertised heavily, in what was called by many the "Cold War," according to historian Gregg Mittman.  Consumers started purchasing various antihistamine products believing that they were buying a cure for allergies and colds.  Mittman says that sales of antihistamines boomed.  

People were taking the medicine without reservation, and they were giving it to their kids.  Yet it didn't take long before parents realized antihistamines didn't cure hay fever, and had little effect on colds.  In fact, some were even noticing side effects, especially in children.  In the process of drying out the nasal passages and stopping the nasal drip, the medicine caused dehydration of the respiratory tract, especially if used in excess.  This caused wheezing, and possibly other asthma symptoms.

Mittman explains that "The initial attack on OTC antihistamine drugs came not from consumers or the FDA but from the AMA (American Medical Association)."  So while some were claiming antihistamines were the new miracle drug for colds, "Austin Smith, editor of the Journal of the AMA, declared that 'no one yet knows what harmful effects (antihistamines) may produce on the body in general, or on specific tissues, when taken over prolonged periods of time." (1, page 227)

Various groups started calling for the FDA to force manufacturers of the medicine to list potential side effects.  Mittan quotes the New England Journal of Medicine:  "This is the most striking example to date of the advertising methods of manufacturers and promoters who are steadily going over the heads of the medical profession in attempts essentially to force physicians through their trumped-up public demand to accept remedies before their usefulness has been adequately substantiated and ill effects determined." (2)

Mittman adds:  "While the FTC (Federal Trade Commission) deliberated over whether drug companies had violated federal trade laws, physicians stepped up their attack by alerting the public to the inherent dangers of antihistamines, particularly for children."  Voila.  That's what I was getting at.  I was a child, a direct recipient of this scare. As far as I know the scare may have saved lives, but it forced me to suffer (note: I may have suffered even with antihistamines, although, considering they help me today, I'm going to assume they'd help me back then).  (1, page 230)

Herman Bundesen, president of the Chicago Board of Health, warned that some children had died after "indiscriminate antihistamines use."  Likewise, "Children taking antihistamines for allergy or colds, advised Bundesen, needed to be placed under a physician's care.  Bundesen also advised caution and restraint in embracing antihistamines as the magical cure for children's allergies.  As much as parents might wish it, antihistamines did not eliminate the need for shots, special diets, or environmental control of the home.  The therapeutic effectiveness of antihistamines varied, Bundesen insisted, according to place -- in this case, the body of an individual child" (3)

A June 1950 compromise by the FTC allowed advertisers to continue advertising the products, although they could no longer say that they would "cure, prevent, abort, eliminate, stop, or shorten the duration of the common cold."  In other words, nothing changed.  There was nothing in the FTC decision regarding safety of the medicine. Advertisers, according to Mittman, were allowed to continue as they were already doing. (1, page 230)

The AMA was unhappy by the ruling.  However, an editor in Collier's was "cynical" the way I'm cynical regarding the medical industry (at times). The editorial suggested the AMA was merely hoping "to give the prescribing physician a monopoly on the first promising remedy that ever came along."

I think the same can be said of Ventolin of 2012.  Could you imagine how much business doctors would lose if Ventolin was available over the counter. Asthmatics with little money wouldn't be forced to pay for a doctor to get their hands on one, and they wouldn't have to pay $75 a pop, because the price would undoubtedly go down.  Patients, and parents, could decide how to treat asthma, as opposed to physicians.

I'm not petitioning for OTC Ventolin, I'm just making an example here.  Although, I think instead of scaring parents and doctors away from antihistamine use, the OTC should have provided doctors and parents with a warning such as:  "Use this medicine with caution for young asthmatics.  Consider the benefits with the risks, which are.... if you absolutely need to use this medicine, stop using it if your child appears to have an asthmatic attack as a result of taking the medicine."

Such a warning would have prevented abstaining use for asthmatic/ allergic children such as myself, patients who truly needed the medicine.

So in the 1950s and 1960s there was an ongoing battle:  doctors wanted allergy sufferers to see a doctor, and FTC and FDA wanted patients to be able to treat their own allergies, much like they treat their own colds.  (1, page 231)

To add to the scare, it must be added here that by that Mittman notes that by the mid 1950s it was observed that antihistamines did not do anything to stop an asthma attack, that was a job for bronchodilators.  (1, page 231) This must have been an added disincentive for doctors to prescribe antihistamines for young asthmatics.

Adults could do whatever was needed to get the medicine that allowed them to function in life.  Yet a child, as I was in the 1970s, had to rely on his physician and parents to not only observe the allergy and cold symptoms, but to do something about it.  I was basically at the whim of the warning on the box that warned against using on children and especially children with asthma. As a result I had to suffer despite the remedy in the medicine cabinet.

Instead of doing that, instead of scaring physicians from prescribing a medicine that might have taken the edge off the suffering of a boy with allergies and asthma, they should have warned physicians to weigh the possible advantages with possible side effects.  Physicians should have been warned to trial patients on the antihistamines, although monitor them closely.

Parents should not have been scared into not giving antihistamines to the one person in the household who would truly benefit from them.  Because, I can honestly say, while antihistamines don't take away all the symptoms of allergies, they sure do help.  Today I use Claratin every day, and it's a wonderful medicine.  Claritin is nice not only because it relieves and prevents allergy symptoms, it doesn't make you drowsy like Benadryl.

I also have to add here that when I was a patient at National Jewish Hospital/ National Asthma Center in Denver in 1985, my doctors there prescribed a daily dose of Drixoral.  Yet when I returned home my mom told me I didn't need it so she quit buying it for me. The irony is I probably needed the Drixorol more at home where the entire house was full of allergens, as compared to at the hospital where the only allergens was pollen and whatever other pollution was in the outside air (and only when I was outside, considering most windows were sealed).

So I suppose there was ignorance on both sides of the isle here.  Still, it frustrates me as I look back.  It frustrates me as I see myself suffering, and out of ignorance I wasn't treated. Although, as the old saying goes, do the best you can with the knowledge you know today, and as you learn better you do better.

My parents were also told to get rid of the dog.  My parents were also told to get rid of the plants.  My parents were told lots of things, and they didn't do much.  They did do some.  They replaced the wood heating vents in my room with steam heating vents.  Yet they still burned wood in the basement, and stored wood down there, because it was a cheaper way to heat the house.  Lord knows wood holds mold, and wood smoke triggers asthma by itself.

I empathize with my parents not doing much, however, because they were simply trying to live within their means  Plus neither of the had asthma or allergies, so even while they witnessed my suffering, they may not have fully understood it

I think of those years every time a young asthmatic passes through the ER when I'm working.  I treat patients with a heavy heart when they are in the ER because they can't afford Advair, which costs $220 a pop , or even Ventolin, which costs $73 a pop.  Lacking health insurance, lacking a good paying job, many of these asthmatic/ allergy sufferers have no option but to go to the ER when their asthma acts up.  They have to treat exacerbations as opposed to preventing symptoms. (Prices are in 2012 values)

References:

1. Mittman, Gregg, "Breathing Space," 2007, New Haven and London, Yale University Press
2. Mittman, op cit, page 229, quoted from: "MDs Hit Unlimited Antihistamine Use," Drug Trade News, 9 January, 1950, page 35
3. Mittman, op cit, page 230, quoted from:  Herman Bundesen, "Dangers for Youngsters in Antihistamines," Ladies' Home Journal, June 1950, pages 192, 194

1850s: The stomach causes asthma

Due to the relationship between the stomach and lungs, "in no direction is asthma more accessible than through the stomach," or so surmised the infamous asthma expert Dr. Henry Hyde Salter.  And, therefore, one of the best ways of preventing asthma attacks is by eating small, healthy meals.  

The reason for this is "due to the close relationship between the stomach and lungs," writes Salter.  What you put into your stomach can and will trigger your asthma, and therefore, to prevent an attack, you must consider a proper eating regimen, and this is among the first things Dr. Salter would consider when taking you in as an asthma patient.  The remedy that worked was a remedy, and the preventative treatment was to eat less food on Sundays.  

For instance, Dr. Salter was requested at the home of a boy who presented with a case of asthma.  Upon questioning the boy and his family, Dr. Salter realized that the attacks occurred every Monday.  Then, upon further questioning, it was learned that Sundays was a day when the family participated in a great feast.  So it was wise of Dr. Salter to surmise the asthma was brought on through due to a full stomach.

So there are various ways asthma can be caused through the stomach. (1, page 135)

1.  Dyspepsia:  (Upset stomach; indigestion)  Asthmatics are generally dyspeptics. Rarely do you find an asthmatics with a perfectly strong, sound stomach.  "The stomach and lung symptoms are part of one morbid condition; the whole thing is deranged pneumogastric innervation, and the asthma of the pulmonary portion of it." (1, page 135)

• Their stomachs are irritable, 
• Their digestion capricious and irregular
• Dietary restricted

2.  Errors in diet:  "To prevent asthma the most scrupulous care is necessary in all that relates to food," with any of the following bringing on an attack:

• A debauch (self indulgence)
• A late dinner
• A heavy supper*

3.  After meals:  Asthma has a tendency to follow shortly after meals, and when an attack is on the asthmatic will feel obliged to starve as long as the attack is upon him.  Since the asthmatic will continue to have an appetite for food, this starvation only adds to the suffering.  (1, page 137)

4.  Gastric symptoms: 

•  Flatulence
•  Hiccough,
•  Etc.  

By the observation that any of the above may cause asthma that Salter came up with his theory that "the taking of food (either by its mere presence in the stomach, or by the process or results of digestion) acts as an irritant to the morbidity irritable pulmonary nervous system. The affair is excito-motory; the food is the immediate or remote irritant, the nervous circuit involved is the pneumogastric, and perhaps in part the sympathetic; and, in obedience to the common law of reflex action, the potency of the stimulus is increased, or, in other words, the reflex nervous irritability is exalted, by the condition of sleep."

The remedy:  Basically, a diet should have consist of three qualities: it should be small in quantity, highly nourishing, and of easy digestion. 

• Eat a healthy diet
• Don't eat too late in the day, or too soon before sleep*
• Do not eat food that is indigestible (should be plain and well cooked)
• Foods should vary; do not give same foods over and over again
• Foods should be nutritious (due to less food eaten in a day by asthmatis)
• Avoid meat pies, beef steak, kidney pudding 
• Avoid drinks containing carbolic acid (Bottled Scout, Scotch ale, etc.)
• Avoid strong coffee with sugar (undigestible)
• Avoid any unwholsome foods (as in all of the above)
• Avoid eating too much (because it's indigestible, not because a full stomach presses up on diaphragm)
• It is better to eat a large meal at breakfast, as opposed to a large meal at dinner time (this may be due to the fact the stomach has better digesting power in the morning.  As the day progresses, the digesting power becomes "exhausted by succeeding meals) (1, page 141)
• Nights rest (restores digesting power of stomach)

The most important thing to remember regarding diet is this:  *let no food betaken after such a time in the day as will allow digestion being completed and the stomach empty before going to bed

The following is Salter's recommended asthma diet:

For breakfast, a small basin, or breakfast-cup, of bread-and-milk, and besides this, an egg (two for a strong man with a good appetite), or a mutton-chop, or some cold chicken or game. As a drink, if any is required besides the bread-and-milk, I think tea is better.than coffee, cocoa better than tea, and milk-and-water better than either. For dinner (not before two or after four o'clock), let mutton be the staple meat, beef or lamb but rarely, pork or veal never. A little succulent vegetable and potato should be taken; and a little farinaceous pudding, or stewed fruit, or the fruit of a tart, should conclude the dinner. Only one helping of either meat or pudding. I believe, unless there is some special reason to the contrary, that water is the be3t accompaniment to an asthmatic's dinner. No cheese, no dessert. A great sufferer from hay asthma tells me that a little boiled fish and brandy-and-water have the least tendency to bring on his asthma of anything he can take; he can take this when a dinner of butchers' meat would be certain to be followed by difficult breathing. With regard to the brandy-and-water I will not speak positively of its advantages in hay asthma, but in ordinary asthma I do not like stimulus of any kind. With regard to the fish there can be no doubt that it is less of a diet, yields more readily and rapidly to digestion, than butchers' meat, and is, therefore, less provocative of any evil depending on prolonged and laborious digestive effort.' And here let me observe that butchers' meat is of all foods (with the exception of those particular articles of diet which are specially offensive to asthma, and to which I shall refer presently) that which is most apt to aggravate asthmatic dyspnoea, and it is because dinner is a meat meal that it is necessary to take it so early. From any occasional late meal that convenience, or circumstances, may force upon the asthmatic, butchers' meat should always be excluded.

Basically, based on this theory, Salter would question his patient as to his diet.  If you have an asthmatic, for instance, who eats butchers meat every day at 1 p.m. and who later has an asthma attack, then the solution may be eliminating the butchers meat.  If someone eats too late in the day, perhaps the solution is to eat earlier, eat less, or stay up later.

Now keep in mind here this is just a recommendation.  Salter was of the belief that what works for one asthmatic may not work for another, and that is why he was usually up to the idea of the patient experimenting to find what remedy -- or diet -- works best for him.

*A heavy supper causes a full and bloated stomach.  This will cause the stomach to press up against the diaphragm creating less room for the lungs to expand.  Some believe this causes asthma.  Salter believes this theory to be false, that a full stomach causes asthma because "the bulk of the food diminished digesting power by over-distending the stomach and so paralyzing its movements, and by being altogether in excess of the secreting powers of the gastric mucous membrane."  This in turn renders the food indigestible. If the mechanical theory were true the asthma would come on in direct proportion to the stomachs bulk, which is not true.  When eating healthy foods, such as arrow root, one can eat all he wants and this will not bring on a fit of asthma.  He may drink water all he wants, and this will not cause asthma. Another proof of Salter's theory is that asthma does not come on immediately after eating when the stomach is most full, but an hour or two later. Relief by an emetic is not mechanical, as it relieves asthma the moment nausea is felt, not upon vomiting. An emetic works even when the stomach is empty.(1, page 141)

References:

• Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment," 1882, New York, William Wood and Company, pages 168-9  (original publication of chapters in magazines during the 1850s. The articles were compiled and published as a book, the first edition of which was in 1860 in London)

1867: Steam powered inhalers

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, etc.  It was something that appeared to provide some immediate relief to the airways and breathing.  And it was also very easy to apply medication to the water to be inhaled.

Stern's Inhaler (3)

There were many methods available, some of which I will mention here.  Although please note that these are but a few samples.  If you had trouble enough with your breathing, you could get quite creative in seeking a remedy or cure.

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 t prevent scolding. You can read more about this inhaler here. 

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, and 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 describes dipping a sponge into boiling hot water, place your face into the sponge, and inhale.  If you like you can drop some medications onto the sponge for direct inhalation.  It's 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.

4.  Wine Bottle or jug:  Another simple method mentioned by Dr. Scutter is 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.  You could use the sponge or wine bottle method, or a combination, and place a towel over your head for the full steam effect.  You 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.

Dr. Mudge's Inhaler

5.  Phillip Stern's Contraption (1768):  It's a unique design playing on the Hippocratic inhaler. Dr. Cohen describes it well.  The lid is angled in a conic fashion so that it creates a pointed mouthpiece whereby the patient places his lips over the device, inhales, and then takes his mouth off to exhale.  Her 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. To learn more about this "inhaler" click here.

6.  Dr. Mudge's Patented Inhaler (1778):  It's another design based on the Hippocratic model, and it's the first inhaler to allow both inhalation and exhalation through the inhaler.  Mudge was also the first to use the term "inhaler," and because Dr. Stern wasn't respected by the medical community, is given credit as the inventor of the inhaler.  Dr. Mudge describes this inhaler well in his book.  To learn more about this inhaler click here. 

Flask inhaler (2)

4.  Flask inhaler:  Dr. Scutter describes that 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 requires is a container that can hold heated water, and "a tube to conduct that vapor to the patient.   Fig. 1, represents such an instrument. The flask is made of flint glass, and will usually bear an elevated temperature. The cork is 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." (2, page 28-9)

Tin cup inhaler (2)

5.  Tin cup inhaler:  Another cheap method of making an inhaler (see figure 2).  Dr. Scutter mentions that he often recommends this in place of the (much preferred) Nelson Inhaler (see below).  In the words of Scutter:  "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 sufiicient 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."

Wolfe-Bottle Inhaler (1)

6.  Wolfe-Bottle Inhaler:  Cohen describes the 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)

Mackenzie's Eclectic Inhaler (1)

7. Mackenzie's Eclectic Inhaler:  It was one of the most "complete instruments of it's kind," wrote 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.  One of the openings on the lid consisted of a pipe to allow free flow of air so you could breathe through the inhaler.  The other opening was attached a hose to  to allow you to inhale the steam.  (1, page 24)


Mandl Inhaler (1)

8.  Mandl's Inhaler or Fumigator:  This is a smaller version of the eclectic inhaler with some advancements.  The lamp is inserted to the bottom of the vessel to gain better control of the temperature of the water.  Cohen notes 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." 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)

9.  The Nelson Inhaler:  This was by far the best of all the steam powered inhalers, and is actually still available in 2012.  The most marketable aspect of this inhaler is it allows the patient to inhale steam, or medicated steam, through a device that is portable.  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."  Over time a variety of marketers copied this design. The inhaler was one of the most common inhalers due to its simple design.    For pictures and more information about this inhaler click here.  

As you look into old physician's books and medical equipment magazines for the 18th, 19th and early 20th centuries you'll find many other designs for steam inhalers, although the basic design is similar to the ones described here.  

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
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-

476 A.D.: The fall of Rome

Nothing may be more significant to the history of asthma, or medicine in general, than the fall of the mighty Roman Empire.  For it is a fact that as Rome fell, so to did all knowledge.  As all knowledge fell, so to did knowledge of science, philosophy, and medicine.

There was a time when Romans believed their empire would last forever.  In a sense, they may even have taken it for granted.  The reason for the decline is still being debated to this day, although the following are often credited:  (5, page 41-2)

1. Rome was too large to be managed.  Rome was so spread out it was difficult to communicate  with people and inspire them to join the military, participate in government, or create industry.  
2. Christianity distracted leaders from problems of the empire, which required intense concentration to remedy.  
3. Able and educated men became Bishops rather than become military leaders in a defunct military or become governors in a nation that was falling apart.  Fixing the government seemed a hopeless task.  
4. Population declined markedly between 250-400 A.D. mainly due to the bubonic plague.
5. Rome had a weak economy, weakened more by population declined.  The economy worsened as markets shrank, and international trade declined.  
6. The inability to form a industrial technology to support nation (no specialization)
7. Regions became more dependent on themselves, weakening the whole (the Empire)
8. Taxes were high, and an alienated populace didn't want to pay them
9. Slavery.  Before 200 A.D. there were wars and slaves captured to do the work.  When wars were no longer needed, the number of slaves declined, yet by then Roman aristocracy were so spoiled they were too lazy to do the work themselves

Many scholars provide most of the blame for the fall of Rome, and eventually the decline of science and medicine, to the rise of Christianity, which started in Rome as a secret society and grew to be a credible institution. 

Yet Historian  Edward Withington claims this theory is far overblown.  He writes:  (1, page 119)

It must be admitted that the triumph of our holy religion, though by no means so responsible for the decline of medicine as is sometimes asserted, nevertheless tended to hasten than to hinder the downfall; but by means of one great institution it has, in the long run, done far more to further the healing art than it ever did to injure it."

Withington explains that various Christians, out of their good hearts, established some of the world's first hospitals and even an ambulance service.  He explains that:

"There is, I believe, no certain evidence of any medical institution supported by the voluntary contributions of the people, or by private munificence, till we come to the Christian days.  The primitive Church, as we learn from the Acts of the Apostles, cared for it's poor from the earliest time, but we find no definite notice of any special buildings for the reception of the sick till the close of the fourth century.  St. Jerome, writing about 400 A.D., says, that Fabiola, a noble Roman lady and his own friend, was the first to build a hospital."

 Withington proceeds to list various Christian hospitals. (1, page 119)

Regardless, Christianity enveloped western Europe, and in 476 A.D. German barbarians crushed Rome to a pulp, destroying libraries and places of learning.  Germans and Christians intentionally cast away all "the gifts of Athens and Alexandria," because the material world that evolved through technology was the antithesis of an eternal life with God in heaven. (2, page 84)

William Osler, in a 1913 lecture at Yale, explains that:

"Knowledge other than that which made a man 'wise unto salvation' was useless.  All that was necessary was contained in the Bible or taught by the Church.  This simple creed brought consolation thousands and illumined the lives of some of the noblest of men.  But 'in seeking a heavenly home man lost his bearing upon earth.'" (2, page 85?)

Other historians provide most of the blame for the fall of Rome on slavery.  In the early days of Rome there were only a few slaves, with most of them working on farms.  Most Romans were farmers in these days, and they were the people recruited to fight wars.  As Rome continued to win wars, the number of slaves skyrocketed.  It got to the point that there were more slaves than Romans who work for hire.  It got to the point that there were even more foreigners than Romans fighting Roman wars, according to historian Harold Johnston.  (6, page 87)

The country was almost completely run by foreigners, many of whom were better educated than their Roman masters.  Johnston explains that:. (6, page 87)

Ruinous as were the economic results of slavery, the moral effects were no less destructive. It is to slavery more than to anything else that is due the change in the character of the Romans in the first century of the Empire. With slaves swarming in their houses, ministering to their luxury, pandering to their appetites, directing their amusements, managing their business, and even educating their children, it is no wonder that the old Roman virtues of simplicity, frugality, and temperance declined and perished. And with the passing of Roman manhood into oriental effeminacy began the passing of Roman sway over the civilized world.

You can see how easy it was for the average Roman to become dependent on the slaves.  It got to the point that when the economy collapsed, it was difficult to get the average Roman excited about doing the work.

By the beginning of the 5th century German Barbarians were allowed to live in peace with the Romans in Rome.  So between slaves and Germans, foreigners far outnumbered Romans.  So, in 476 A.D., when the German Barbarians attacked Rome, there was little the natural born citizens of Rome could do to stop them.

These barbarians wanted to completely demolish Rome and all it stood for, and so they destroyed the libraries and places of learning.  While watching these places burn, the Germans were watching the demise of all knowledge of philosophy, science and medicine.  It would all be lost for over a thousand years.

References:

1. Withington, Edward Theodore, "Medical History from the Earliest Times: A Popular History of the Art of Healing," 1894, London, The Scientific Press. 
2. Osler, William Henry, "The Evolution of Modern Medicine: A series of lectures delivered at Yale..." page 85
3. Meryon, "
4. Cantor, Norman F, "The Civilization of the Middle Ages: A Completely Revised and Expanded Edition of Medieval History," 1993, first edition, Harper Collins Publishers
5. Cantor, Norman, "The Civilization of the Middle Ages: A Completely Revised and expanded Edition of Medieval history: The Life and Deal of a Civilization," 1993, Harper Collins Publishers, New York
6. Johnston, Harold Whetstone, "The Private Life of Romans," 1908, Chicago, Atlanta, New York, Scott, Foresman and company

760-370 B.C.: How did Hippocrates assess his patients

Hippocrates examining a child, a painting by Robert Thom, 1950's.

Hippocrates became the most famous physicians of ancient Greece during the Age of Pericles by his skill and gentle approach as a physician. His approach to medicine was highly regarded not just by his patients, but by his peers. By his example, and through his writings, he would almost single handily improve the image of medicine.

In order to help future physicians develop the skills and technique needed to become a respected physician, and to create a good image of the profession, he compiled all the medical wisdom from the school of Cos into a series of 60 medical treaties called The Hippocratic Corpus.  

Most historians now believe that he did not write all of the Corpus by himself, although most would agree that he was, for whatever reason, the most significant and respected physician of his era, and for this reason his name is attributed to the treaties.  It would go on to become the cornerstone of Greek medicine, and all of medicine for the next 2,000 plus years.  

In this way, Hippocrates became the most famous physicians of his era and all time.  Not only was he referred to as "The Great Physicians" during his time by the philosopher Plato, but he is referred to by most historians as "The Father of Medicine." 

By resorting to simple or natural remedies first, Hippocrates, like other physicians at the school of Cos, preferred the medical philosophy of looking out for the best interest of the patient, and to avoid risky treatment.  Such may be evident by the motto "first do no harm."

When Hippocrates was called to help a patient, he would pack his bags and travel to the patient's home.  As he was taught by his predecessors at the school of Cos, he would consider the patient as a whole.  As noted by 18th century physicians Bernardino Ramazzini, Hippocrates encouraged the following: 

'When you come to a patient's house, you should ask him what sort of pain he has, what caused them, how many days he has been ill, whether the bowels are working and what sort of food he eats.' (1, page 15)

Of the assessment of the patient, Garrison said:

Hippocrates instituted, for the first time, a careful, systemic, and thorough-going examination of the patient's condition, including the facial appearance, pulse, temperature, respiration, excreta, sputum, localized pains, and movements of the body. (2, page 89-90) 

Medical historian Max Neuburger said the following were also assessed:

Odour of the sweat, of the sputum, of the vomit, the urine, the faeces, of the discharge from wounds; the taste of skin secretions, of wax from the ear, of nasal mucus, of the tears and sputum (sweet or the contrary) and of diverse other body fluids had to be investigated, partly by the physician, partly by the patient himself.  (5, page 145)

The color, consistency, and smell of phlegm was also assessed.  The assessment was useful in helping the physician come up with a diagnosis and prognosis, which would help determine if the patient was curable.  If the patient was curable, the prognosis was used to determine the eventual remedy or cure. 

For instance, as noted by Neuburger:

Yellow sputum, mixed with a little blood, occurring at the beginning of the illness in a patient suffering from inflammation of the lungs is a sign that he will recover, and is beneficial, occurring for the first time about the seventh day it is a somewhat surer sign.  (5, page 145)

Hippocrates himself wrote the following of his assessment:

Thus, it considers the voice, as to its clearness or hoarseness. It examines the discharges from certain regular channels; and drawing consequences from their odour, colour, consistence or fluidity,—he judges of the character of the disorders, and the existing state of the patient; and by the same means, medicine is even enabled, not only to ascertain the past, but likewise his future state. After having thus become acquainted with diseases, by their symptoms, if nature is unable to effect a cure, art then teaches how to excite those salutary movements, by which, without danger, the system may discharge itself of what is injurious to it. (3)

Regarding the movements of the body, Hippocrates was known to listen to a patient's heart and lung sounds by placing his ear upon his patient's chest, although if he wanted a more thorough examination of the humours inside the patient's chest, he would shake the patient, gently perhaps. This allowed him to hear secretions, if they were present, in the patient's chest.  (2, page 90)(5, page 146)

The procedure was called succussion, and was mainly used to recognize the presence of pus in the lungs to diagnose the presence of an empyema. In fact, if a physician performed the procedure and failed to diagnose empyema when it was present, this was considered a "sign of lack of surgical dexterity," said Neuburger. (5, page 157)

According to Neuburger:

This shaking was supposed to effect the outflow of pus from the parenchyma of the lung by way of the bronchi... Recognition during this process of teh splashing sound which occasionally occurred (in pyo- and hydropneumothorax, but also in bronchiectasis and cavities) resulted in the employment of succussion (known now as Hippocratic succussion) as a diagnostic method in order to determine whether and where pus were situated in the pleural cavity, also the most suitable spot for incision in thoracocentesis (a procedure involveing placing a needle into the chest and drawing up the excessive pus in the pleural space, or the cavity surrounding the lungs).  (5, page 146)

Neuburger said that succussion was also used to diagnose empyema (pus in the pleural space).  He said, "If it, and the pouring of fluid into the throat to excite coughing and expulsion of the pus, fail, then the operation of thoracocentesis is called for." (5, page 146)

Sounds other that the rare secretions heard upon succussion were also listened for by auscultation.  Some conditions caused a rattling sound in the trachea.  Diseases such as pneumothorax might cause crepitations, which is air bubbles under the surface of the skin, particularly on the upper chest area.  Pleuritic frictions, or what is now called a pleural rub, was also listened for.  This might indicate pleural a collapsed lung (pneumothorax) or other such malady.

Certain noises in the chest may indicate hydrops of the lungs, or what would now be considered pulmonary edema caused by heart failure, kidney failure, or sometimes pneumonia.  Hydrops is an old term for water in the lungs.  Of this, Neuburger wrote:

Of the diagnosis of "Hydrops of the lung" it is stated: "When the ear is held to the side and one listens for some time, it may be heard to deethe inside like vinegar."  A pleuritic friction is well described... "A grinding may be heard which sounds as if it came from two leather straps."

The Hippocratic concept also took into consideration the desires of the patient. As noted by Withington:

The wishes, and even the whims of the patient are to be indulged as far as possible, and a physician should rather lose his fee than trouble a sick person about it, for the memory of a good deed is better than a temporary advantage. He should also neglect no opportunity of serving the poor and the stranger, for "where the love of the art is, there is the love of man ". This last quotation, indeed, is from a work of very doubtful authorship, but it expresses the spirit, if not the words of Hippocrates. (4, page 51)

He paid attention to the prognosis more so than the diagnosis.  According to Neuburger, was "that the preservatoin of the organism be his goal."  He was well aware of the "limitations and of the potentialities of his art."  And he made sure he "occupied himself only with those diseases in which a cure might be anticipated and approached the sick-bed inspired by the principle: 'Do good, or at least do no harm.'" (5, page 147)
He spared no effort to ease the mind of the suffering, even when he knew there was no chance that his remedies would cure the patient's disease.

References:

1. Ramazzini, Bernardino, writer, "Disease of Workers," Wilmer Cave Wright, translator, 1964, New York, Hafner,  (8)
2. Garrison, Fielding Hudson, "An introduction to the history of medicine, 1922, (9)
3. Hippocrates, "The Art of Medicine," Section I, Treaties III, translated by John Redman Coxe, "The writings of Hippocrates and Galen," 1846, Philadelphia, Lindsay and Blakiston (10)
4. Withington, Edward Theodore, "Medical History from the Earliest Times: A Popular History of the Art of Healing," 1894, London, The Scientific Press.  (3)
5. Neuburger, Max, writer, "History of Medicine," 1910, translated by Ernest Playfair, Volume 1, London, Oxford University Press

639-322 B.C.: Greek medicine was key

Greek philosophy was the key to all medical knowledge through history. Later on in our history we will see that when Rome fell, all knowledge of philosophy was lost to western civilization, and therefore it became engulfed in a dark ages of medicine. This era lasted for over a thousand years, until the key was rediscovered.

So how did Greek medicine become the key to all medical knowledge? As we've learned, the Ancient Greeks were the first people to have time to sit around and think, and they basically became our first philosophers. So curious were these philosophers that they traveled the world and visited with all the sages, and upon returning to Greece they added this wisdom to the pantheon of philosophical wisdom.

Among this wisdom was all the knowledge of medicine that existed. This made Greek philosophy the key to all medical wisdom. Their medicine was basically one based on philosophy, and it evolved over a period of hundreds of years, stacking the theories of one great philosopher on to the theories of another.

This key is important to our asthma history because it would determine how your asthma was treated. Here I will list some of the key figures from Ancient Greece as far as their medicine is concerned, with a pithy explanation of that person's contribution.

You can kind of bare with me as we proceed through this, and by the end you should see the connection with modern medicine, or I so hope Ready? Here we go*!

1. Thales of Miletus (639-544 B.C.): Garrison, in his 1922 history of medicine, said "he was taught under Egyptian priests, and taught that water is the primary element from which all else is derived." (1)

2. Anaximander of Miletus (611 B.C.): Garrison said "he mapped the heavens and made a successful prediction of an eclipse."(1) Perhaps he did this while working with Thales, because Sigerist credited Thales as accomplishing this feat. He believed the common elements were fire, air, water and earth, and their qualities were wet, dry, hot and cold. He believed they were all caused by a primary substance. From this the idea of two primary elements with opposite qualities was born. In a healthy person they were in balance. This theory would go on to become a significant part of Greek medical theory. (2, page 91) It must be assumed her that he did not create these elements and qualities, simply introduced them into Greek philosophy.

3. Pythagoras of Samos at Crotona (580-489 B.C.): Garrison said he studied in Egypt and it is probably from here that he "acquired his doctrine of the mystic power of numbers... (of which) the numbers three and four represent the worlds, the spheres, and the primordial elements" (earth, air, fire, water). He was also the first to associate the brain as the "central organ of higher activities." (1)

Sigerist said that while he believed in the elements and qualities, he believed the number was the most significant. He said:

Among the numbers, four played a significant part, for it seemed logical that two pairs of forces with opposite qualities would constitute an ideal balance, and we shall see that this view had a profound influence on medical theory, as had the Pythagorean doctrine of opposites of its dualistic form in general. These opposites were necessary to explain the harmony of the world. (2, page 97)

He believed that a balance of the internal qualities must be achieved in order to
maintain health, and this was maintained by "practicing moderation." When a person was unhealthy it was because the balance was disturbed. Health was therefore re-established physically by medicine, and mentally by music. (2, page 96-98)

Neuburger said some of the internal materials present in the body that needed to be balanced were cold, moist, warm, dry, sweet, and bitter. Empedocles would later limit these to four.   (13, page 107)

As can be assumed with some degree of accuracy, he basically compiled all the wisdom of the sages of the world, and all the wisdom of the earlier philosophers of Greece, and created a large following who listened to his lectures. He even organized his followers into a school, and in this way he made philosophy popular in Greece, and is often given credit for giving birth to the Age of Philosophers in ancient Greece.

You can read more about Thales, Anaximander, and Pythagoras in this post. (1)

4. Anaximenes of Miletus (570-500 B.C.): He lived about the same time as Pythagoras. Garrison siad he "assumed that indivisible matter (earth?), air, or fire respectively are the primordial elements."(1) Sigerist said he believed that of the elements of earth, air, fire and water, that air was the primary element. Of this, Sigerist said: (2, page 92)

He wrote a book of which one sentence has survived: "As our soul, being air, holds us together, so do breath and air surround the whole universe." (2, page 92)

He believed air was essential for sustaining life, and that it was also evident in the soul. He believed air was the primary element because he believed the others were "born from it through changes of density," said Sigerist, "through rarification and condensation." As a note here, rarification is an old term meaning that the air pressure is decreased. Condensation means the air pressure has become increased. (5, page 92)
Sigerist continued, "Rarified air became fire, and heat was generated in the process, while condensed air became water and finally earth, and produced cold. This was a logical explanation, and breath or air came to play an increasingly important part in biology." (2, page 92)

5. Heraclitus of Ephesus (556-460 B.C.): Same contribution as Anaximenes.(1) Sigerist said he believed everything changes constantly, and therefore he believed the primary element was fire because it caused things to change. He believed fire produced air, water and earth. Fire, like war, causes strife, and the polar opposite of war and fire causes peace and unity (or balance).
Sigerist quotes him as saying: (2, page 93)

That which is in opposition is in concert, and from things that differ comes the most beautiful harmony." (2, page 93)

Sigerist said that, quoting Heraclitus along the way, "It is through opposites that we become aware of things. Disease 'makes health pleasant; evil, good; hunger, plenty; weariness, rest.' And everything in the world moves according to eternal laws. These very principles, unity of the world, eternal changing of all things caused by tension, and law and order ruling the world, were principles which proved to be strong stimulants to scientific research." (5, page 93-94)

You can read more about his theory of opposites by clicking here.

6. Anaxagorus of Clazomenae (500-428 B.C.): He assumed the four elements (earth, air, fire, water) to be made up of as many parts or 'seed' as there are varieties of sensible or perceptible matter. (1)

7.  Empedocles of Agrigentuin in Sicily (504-443 B.C.): Medical historian Edward Withington said he first mentioned the four elements, which would later influence Greek medicine, in the following poem:  (7, page 45)

Listen, first, while I sing the four-fold root of creation,
Fire, and water, and earth, and the boundless height and the aether, For therefrom is begotten what is, what was, and what shall be. (7, page 45)

Withington explained that by... 

"...substituting air for aether, this is the doctrine of the four elements, which Empedocles introduced into philosophy, and which, with the co responding four qualities, heat, cold, moisture, and dryness, and the four humours, blood, phlegm, black and yellow bile, lies the basis of Greek medical theories." (7, page 45)

Fielding Hudson Garrison verifies this, adds to its significance.  He said:

"He introduced into philosophy the doctrine of the elements (earth, air, fire, water) as 'the four fold root of all things.'  The human body is supposed to be made up of these primordial substances, health resulting from their balance, disease from imbalance.  He holds that nothing can be created or destroyed, and that there is only transformation, which is the modern theory of conservation of energy.  Everything originates from the attraction of the four elements and is destroyed by their repulsion, and he applies the same idea, under the forms of love and hate, to the moral world.  Development is due to the union of dissimilar elements, decay to the return of like to like (air to air, fire to fire, earth to earth)." (1, pages 80)

The association between the four elements, four qualities, four humors, four basic organs, four seasons, and the four personalities can be seen by the following chart.

Element	Quality	Humor (Greek)	Combination	Organ	Season/ Cause	Personality Temperament
Fire	Hot	Blood/ Haima	Wet & Hot	Heart	Spring/ Energetic Hopeful	Sanguine: jovial, social
Air	Dry	Yellow Bile/ Choli	Dry & Hot	Liver	Summer/ Diseases	Choleric: fussy, irritable
Earth	Cold	Black Bile/ Melanchia	Dry & Cold	Spleen Stomach	Autumn/ Melancholy Depressed	Melancholy: depressed, gloomy
Water	Wet	Phlegm/ Phlegm	Wet & Cold	Brain Lungs	Winter/ Coughs, Colds	Phlegmatic: peaceful, laid back

You will see the significant of these played out in pretty much an history of mankind, and definitely in an history of medicine.  While some contribute these to various different authors, such as Aristotle sometimes gets credit for the four elements, and Hippocrates for the four humors, it is the great Empedocles to which they may all be traced back to.

He believed that respiration, along with occurring through the lungs, also occurred through tiny pores in the skin.  (13, page 108-109)

While Empedocles probably wasn't the first to conceive of the idea that something in the air inhaled was essential to life, he created the theory of pneuma.  Pneuma was a substance in the air that contained a vital spirit.  It flowed through the body by veins, providing life to the organs.  It was responsible for movement, consciousness and perception.

8,  Democritus of Abdera (460-370 B.C.):  He was a student of Leucippus, and believed the mind and body were composed of corpuscles or atoms that were solids and unchangeable.  In this way, he believed living things were made of these solid atoms as compared to the humours of Hippocrates.  (14)

He believed the atoms were organized and arranged within the human body by a natural mechanism. (8, page 23)  He believed that inflammation was an accumulation of phlegm.  He believed the "widespread appearance of epidemic disease was... due to the disseminated atoms of shattered heavenly bodies." (13, page 110)

9.  Hippocrates (460-370 B.C.):   Prior to Hippocrates, methods of treating diseases were relatively simple, and taught mostly by word of mouth.  However, stored in the Asclepions were votive tablets, and these contained lists of diseases and their cures.  Hippocrates was the first to take all this wisdom and publish it into a compilation of 60 treaties called the Corpus Hippocraticum.

He believed air was inhaled, and this air contained pneuma.  He actually referred to "breath" as the pneuma, and this pneuma (or breath) flowed through the veins, such as was noted by Empedocles.  In health its flow through the body was unimpeded.

He believed that within each person was a combination of the following qualities: (14)

• Acid
• Saline
• Acerb
• Bitter
• Mild
• Insipid
• Austere (14)

He said each of these was...

...possessed of different powers, in proportion to their quantity and degree of strength. All of these, when well united, and tempered by each other, are insensible to us, and do no injury; but if one should separate, and exist alone, it then becomes sensible, and ravages the system. It is the same with aliment. That which is improper for us, is either bitter, saline, acid, or too strong. (14)

Healthy food, such as bread, barley and cakes, " causes no uneasiness, or any separation of the particles of the humours of the body, and serving only to strengthen, nourish, and promote its growth. All these benefits arise from its well-attempered state, in which nothing predominates, nothing is irritating, nothing too strong. Every thing is reduced to a point, so as to be esteemed simple, homogeneous, and at the same time, of adequate strength." (14)

However, in the process of making such food, things like fire and water are employed, "each having its own peculiar powers and qualities. (The food) loses part of what it had, and what remains is a compound mixture." (14)

In this way, each type of food has its own particular qualities, such that bread has different qualities than cakes.  Likewise, depending on how it was prepared, two different loaves of bread may have unique qualities. (14)

Hippocrates believed, therefore, that eating the wrong food, or too much of the good food, or food that was not prepared correctly, or food that was not part of that person's normal diet, might upset the unity and homeostasis within the body. This, in turn, leads to changes in the four qualities and four humors of Empedocles.

Medical historian Edward Meryon said Hippocrates must have studied the works of Democritus, who believed that a natural process usually worked to maintain a balance (homeostasis, unity) of the atoms.  Hippocrates believed a natural process usually worked to maintain four qualities and four humors of Empodocles in order to maintain health.  Hippocrates taught that any imbalance of the qualities or humors within a person was the cause of disease.  (8, page 23)

Nature worked to maintain balance in health, and to re-establish balance in sickness.  He believed imbalances were generally the result of eating the wrong foods, or changes in the wind, or changes in the temperature, or changes humidity.

His remedies were generally gentle, and merely worked to assist nature in the healing process.  They included simple things such as getting plenty of sleep, taking a bath, eating healthy, and exercise.  

He believed in the maxim:

 "Merely give nature a chance, and diseases will cure themselves."  (3, pages x-xii)

His ideas would transform medicine from one of mythology and philosophy taught at the Asclepions, to a "distinct department of practical knowledge" that could be learned by anyone.  (9)

10.  Plato (427-347 B.C.):  He was a student of Socrates, and became famous for recording the wisdom of the great philosopher.  He then became a famous philosopher himself.  As was normal for the era he was born into, he was educated in all the knowledge of the day, including medicine.

Garison said that his main contribution to medicine was that "In pathology, the plastic significance of the number four was combined with the doctrine of the four elements." This can be seen here (in parenthesis is our modern correspondence): (1)

• hot + dry = fire (hydrogen)
• cold + dry = earth (oxygen)
• hot + moist = air (carbon)
• cold + moist = water (nitrogen) (1)

These could also result in the following:

• hot + moist = blood
• cold + moist = phlegm
• hot + dry = yellow bile
• cold + dry = black bile

The various combinations of these resulted in both the aspect of disease and the action of the drugs used to treat them.  Each person had a unique combination of these and maintained the equilibrium in times of health. Disease was a result of increases and decreases of any of the above.  Health was re-established by making the necessary adjustments.  (1)

Plato believed in the Pythagorean Theory of Opposites, although he also believed there was a "third element mediating between a pair of opposites." He believed the soul completed "the human trinity of body, soul and spirit."   (12, pages 2-4)

He believed the body consisted of a soul with three parts: (11, page 23)

• Rational Soul: Created by the brain 
• Animal Soul: Created in the chest and is responsible for emotions and passions
• Vegetable Soul: Created in the abdomen and controlled physiological needs (11, page 23)

While Plato didn't create any of these ideas, he helped to keep them alive by his fame.  He would also relay this wisdom to his famous pupil, Aristotle.   

11.  Aristotle (384-322):  He was born in Stagira to a wealthy family. His father, Nicomachus, was personal physician to Amyntas, king of Macedon.  He probably learned quite a bit about medicine from his father before, starting when he was 17, spending 20 years being tutored by the great philosopher Plato at his academy in Athens.   (6, page 3)

He would spend about 20 years in Athens as a student, and then as a teacher. Some speculate he left after not being chosen as Plato's successor upon Plato's death in 347 B.C.  Some speculate the reason Aristotle was not chosen, and why he left Athens, was because Aristotle was known to debate and disagree with Plato.  He moved from Athens and continued his work elsewhere. (6, pages 3-5)

Regardless, he basically supported the same ideas regarding medicine as Plato.  He believed in the four elements, qualities, and humors.  He believed that a balance or imbalance of these determined health and sickness.  (1)

While he believed in the elements of Empedocles, he attempted to add a fifth element that he called aether, a substance that made up what was seen in the sky at night, such as the stars, sun, planets, comets, etc.  He was not the first to write about the elements and their qualities, although by the fame he acquired by being the instructor of Alexander the Great he was able to increase public awareness of them.

While he was not a physician, and is known mainly for his contributions to philosophy, he did make some significant contributions to medicine.  Considering he was unable to dissect human beings, he spent most of his time at the dissecting table studying plants and animals.  He was known for his faith in nature, claiming that "Nature does nothing uselessly."  (5)

He stayed in A

12. Erasistratus (304-250 B.C.)  He was among the first Greek anatomists.  He was the beneficiary of the new city, Alexandria, created by Alexander the Great.  After Alexander died before he was 32 years old, Ptolomy decided to make Alexandria the leading place of wisdom and science in the world, so he gave the physicians at Alexandria permission to dissect human beings.  Among these physicians was Erasistratus, who discovered and learned much about the inner workings of the human body.  Some say he even went as far as to dissect living human beings, but all in the name of advancing science and wisdom.

He disregarded the idea the the four humors caused disease, and believed that diseases like pneumonia were caused by changes in the body, such as inflammation of the lungs.  This is the type of wisdom that might have been expounded upon if it wasn't considered sacrosanct to dissect the human body in the ancient world.

13. Herophilus (335-280 B.C.): He was the other leading physician at the school of Alexandria, and he likewise participated in dissection of the human body in a quest to improve wisdom and science. Unlike Erasistratus, he supported Hippocrates and his humoral ideas.

14.  Galen:  He was born during the Roman Civilization, although he still lived in Greece.  He lived in Pergamum, a city that was ruled by the Romans, but they still lived under Greek culture.  Galen learned from all the above physicians, and he basically combined the works of all these great men, particularly combining the theories of Hippocrates with the anatomical discoveries of Erasistratus and Herophilus.

He believed in the humoral theories of health and sickness of Hippocrates. However, while Hippocrates was not concerned with anatomy of the body, Galen came up with theories of how each organ participated in the organisms life giving process.

Galen also believed in the Aristotelian idea that nature makes no flaws, and perhaps from him Galen obtained his belief that God created only perfect human beings, and therefore each part of the body had a perfect function.

Through his writings he described the faculties of nature, whereby each part of the body (veins, arteries, organs, etc.) performed a distinct function in order to maintain life, health and longevity.

He absorbed the idea of Plato of the power of three parts of the soul, although he referred to them as spirit.

• Natural Spirit: Formed in the liver and flowed through the body by veins to the various organs. 
• Animal Spirit: Formed in the brain and responsible for sensation and intelligence
• Vital Spirit: Formed in the heart when air mixed with blood, and flowed through the arteries to the various organs.  It consisted of passions. 

He believed the person ingested food, the food was cooked in the stomach, turned into chyle, sent to the liver by veins, and turned into blood in the liver.  The liver added natural spirit and nutrients to the blood, and sent it to the right ventricle of the  heart to be purified.  The blood was turned into a light, frothy substance so it could enter the lungs, and returned to the right ventricle of the heart as purified blood that ebbed and flowed through the entire system to provide natural spirit and nutrients to the body through the veins.

Some blood from the right ventricle was transferred to the left ventricle by invisible pores.  This blood was mixed with air that was inhaled by the lungs.  Since the heart was hot and controlled the temperature of the body, the cool air was needed to cool the heart.  Air also contained pneuma, and so when the air and pneuma mixed with blood in the left ventricle, it formed vital spirit.  This substance was responsible for the passions of the person, and was transferred through the body by the arterial system.

Some arterial blood went to the brain by vessels from the heart to the brain.  Here this blood was mixed with animal spirit and sensations and intelligence.  These were transported through the body by the various nerves.

His ideas of health and healing were similar to Hippocrates, although he believed changes that occur within one organ can effect the body as a whole.  For example, asthma was caused by increased phlegm in the lungs, epilepsy was caused by increased phlegm in the brain, fever was caused by increased blood, etc.

His remedy was to treat contraries with contraries, or to treat whatever was the suspected cause with the opposite.  If someone has too much phlegm, for example, Galen may with so have the patient drink an purgative or emetic to expectorate the excess phlegm.

Since Galen was the very last of the Greek and Roman physicians when Rome collapsed, and because he wrote so much about it, his works continued to be worshiped for greater than the next 1,500 years.  Basically, Greek medicine survived the dark ages through the works of Galen.

During the Middle Ages the Catholic Church accepted the medical writings of Galen, perhaps because he believed that God created only perfect human beings.  This fit into the Christian belief that god made no flaws.  During this time, anyone who spoke out against the writings of Galen was greatly ridiculed, and sometimes severely punished, sometimes with death.  (4, page 113)

So during the dark ages of medicine Galen became a god, of sorts, of medicine.  His works were like the Bible to physicians.  In this way, Greek medicine was the key, or the foundation of all medical knowledge.  It would only be from using this key that any future advancements in medicine would be made.

References:

1. *The above characters and descriptions are taken from Fielding Hudson Garrison's book, "An introduction to the history of medicine," pages 80-83.  The same information can be obtained in many medical history books, with Garrison's, in my opinion, being the most pithy for our purposes.  
2. Sigerist, Henry E, "A History of Medicine: Early Greek, Hindu and Persian Medicine," Volume II ", 1961, Oxford University Press, pages 88-99
3. Brock, John, "Galen on the natural faculties," 1916, London, New York, William Heinemann, G.P. Putnam's Sons
4. Bendick, Jeanne, Galen and the gateway to medicine," 2002, San Fransisco, Ignatius Press
5. Dunn, P.M., "Aristotle (284-322 B.C.): philosopher and scientist of ancient Greece," Arch Dis Child Fetal Neonatal Ed., January, 2006, 91(1): F75–F77.
6. Lloyd, G.E.R., "Aristotle: The growth and structure of his thought," 1999, UK, Cambridge University Press

   Aristotle (384–322 bc

   Aristotle (384–322 bc

   Aristotle (384–322 bc

7. Withington, Edward Theodore, "Medical History from the earliest times: A popular history of the art of medicine," 1894, London, The Scientific Press
8. Meryon, Edward, "The History of Medicine," Volume I, 1861, London, 
9. Watson, John, "The Medical Profession from the Earliest Times: an anniversary discourse delivered before the New York Academy of Medicine November 7, 1855," 1856, New York, Baker & Godwin 
10. Hippocrates, "The art of medicine in former times," epitomised from the Original Latin translations, by John Redman Coxe, "The writings of Hippocrates and Galen," 1846, Philadelphia,  Lindsay and Blakiston
11. Weckowicz, T.E., H.P. Liebel-Weckowicz, "A history of great ideas in abnormal psychology," 1990, North-Holland, Elsevier Science Publishing Company, Inc. 
12. Nash, John, "Plato: A Forerunner," The Beacon, July/August, 2004, pages 18-24
13. Neuburger, Max, writer, "History of Medicine," 1910, translated by Ernest Playfair, Volume I, London, Oxford University Press
14. Berryman, Sylvia, "Democritus," from the book "The Stanford Encyclopedia of Philosophy," http://plato.stanford.edu/entries/democritus/, 2010, accessed 12/22/13
Hippocrates, "The Art of Medicine," "The writings of Hippocrates and Galen," Epitomized from teh original Latin translations by John Redman Coxe, 1846, Philadelphia, Lindsay and Blakiston