Dr. Office Visit Number 3,343,342, or something like that

So I've probably seen more doctors in my life than 90% of the U.S. population.  Better yet, I've seen more doctors than 99% of people my age.  And I still get nervous.

The doctor comes in.  He shakes my hand.  The usual first question he asks is, "How's your asthma?"  Usually I say, "Good."  Today I say, "It hasn't been a good year for my asthma."  Which is true.  It's been a rough year as I note here and here and to a greater degree here.

He listens too me.  My breath quivers, a nervous quiver.  "You sound like you're moving air good.  But you do have a wheeze in your right upper lobe."  Then he sits down in the doctor chair.  

I tell him about my hunting camp experience, and my experience sorting through old VCRs in the basement, and my using theophylline to end an attack -- five year old theophylline.  I keep a bottle in the cabinet as a memento of the day I took that last pill after 30 years of dependence.  I told him how these asthma attacks occur on weekends, and I don't want to use the ER.

I say, "Maybe I should have a script for theophylline."

He says, "Well, I was thinking I'd give you a medrol pack."

I say, "Ah, even better."

Now you'd think that considering I'm a lifetime extrinsic asthmatic I'd have an asthma action plan and a medrol pack on hand all the time, but I've never had one.  I do now.  

He also gave me two samples of Symbicort to try, again.  He did the same last year.  My experience with that stuff was it works fast but it makes my heart beat like Alupent used to.  I tell him I want to try it again.  So we'll see how that goes.

After bantering a bit, small talk about work, he says, "Well, I'll see you in two months.  I want to keep an eye on you for a while."  He starts to walk out.  I know now I have to ask what my wife wants me to ask, and I'm nervous to ask.  But this is my last chance.

"MywifewantedmetoaskyouifIcanhavesomexanax," I say.  "I don't feel comfortable asking for it, but she thinks I need it."

He smiles, and sits back down.  "Sure, I think we can do that.  Do you think you need it?"

"Well, I have four kids."

"Nuff said." He opens his computer pad, writes something.  "Done."

"I had a prescription once before," I say, "and I decided I better quit.  So when my old doctor asked me if I wanted a new script I said no."

"It's a pretty safe medicine.  It has a slow onset and isn't very addictive.  I think it should be okay."

"Thanks."

"No problem."  He stands.  We shake.  On the way to the car I remember he never mentioned my blood pressure.  He never really even touched me, which is fine by me.  I just wonder if it's a good thing.

1849-1919: The father of modern medicine x

Sir William Henry Osler

The turn of the 19th century was the dawn of modern medicine.  So medicine needed a father, and the man to step into that role was Sir William Henry Osler.

Due to the significance and respect for his character, the ideas he wrote about were seriously considered by the medical community, including what he wrote about asthma

The growth of a legend:

Willie Osler was born to a family with a prominent history. His father was an Anglican minister, and Osler's goal was to follow in his father's footsteps, and it was this goal that landed him in 1867 at Trinity College in Toronto.

Yet this was also a time when physicians and scientists were using science to disprove some old ideas about science and medicine.  Charles Darwin proposed an idea that challenged the age old idea of natural selection, and chose to believe science instead.  Science was in direct competition with religion.

Perhaps it was for this reason that Osler's heart just wasn't in the ministry.  He spent most of his free time reading about medicine.  His heart, and perhaps fate,  lead him ultimately to switch from studying ministry to medical school where he excelled.

He started Medical School at Trinity College where the methods of teaching medicine were primitive and left to the desires of each respective professor.  The college hospital admitted only 25 patients at a time, and medical students could only see patients taken care of by their own physician. (3, page 54)

Once Medical School was complete after three or four years young physicians had little experience working with real patients, and the young Olser took acceptance to this.

Osler believed pathology was essential to improving medical wisdom.
Like other physicians before him, he would have been befuddled by the
lack of scarring caused by asthma.  This must have been what caused him
to deduce, as others had before him, that asthma must be nervous.
For this reason, much of the treatment focuses on the nervous component

Much of his time was spent studying and performing autopsies.  He was often so involved in his work that he ate in the same room he performed these autopsies.  His goal was to learn as much as he could about the human body and medicine.

Most of the classes were taught by local physicians, and payment for these classes was given directly to the professor.  Lectures were mainly given  from old medical textbooks and were "flung at us pellmell without word of guidance, and leaving us standing helpless, bewildered, and starved in the midst of what seemed a superabundance of wealth," wrote Osler.  (3, page 54)

He ultimately transferred to McGill University where his writings, research and ideas quickly won the attention of his fellow students and professors.  He continued to study, research and perform autopsies (while eating in the same room).

During his final year in med school he worked so hard on his graduation thesis on pathologic anatomy that he was rarely seen by his fellow students  His theses would ultimately win accolates "because it was greatly distinguished for originality and research." (1)

It was partly because of this work and the potential in the young Osler that he was offered a job as a teacher at McGill University.  But he declined, choosing instead to attend school in Europe to further his medical wisdom. He did his studies in Vienna and Germany, which were considered to be leading nations in medicine and science at that time.

In 1874 he returned to Canada, and, coincidentally, one of the medical professors at McGill University had resigned.  At the young age of only 25, and with very little experience as a physician, Osler was offered and accepted his first teaching job.  Within a year he was named as a professor of medicine.

He wasn't paid enough money to make a good living as a teacher, so he had to start a practice.  Yet he ultimately became so rapt in his job as a teacher that he gave little attention to his medical practice and other opportunities to make money.  However, he did manage to see patients, including many famous ones. 

His enthusiasm allowed him to get the most out of his students, and he became an instant hit as a teacher.  A year later he became one of the seven founders of the Association of American Physicians, and in 1889 he became one of the first physicians at John Hopkins University.   It was here that his career took off.

A transformation in medicine:

John Hopkins was built on the idea that it would be the best medical hospital in the world. To run its medical school Henry Osler was hired based on his reputation and his bold ideas for the medical profession.

This turned out to be a wise decision, because it was Osler who came up with the idea that medical students learn best when working with actual patients.  He often repeated the maxim:   "Listen to your patient, he is telling you the diagnosis."

While other medical schools were unorganized and offered two or three year programs, John Hopkins would offer a four year program that required a year as an intern working alongside physicians in the medical ward to obtain experience working with real patients.  .

 Osler became rapt in medical wisdom, and loved to share this wisdom.
 Here he is writing "The Principles and Practice of Medicine"

This was the first time this was ever done, and it was a big hit.  It was such a big hit that within a few years many medical school were transforming the way they taught medicine.  No longer would physicians graduate from medical school when their only experience was from lectures, textbooks, and a few random patients.

Through all this time Osler continued to do what he loved best, and that was to study the human body by performing autopsies and reading books.  He spent a ton of time in the morgue, laboratory and library.  He likewise continued to write about what he learned through his experiments and observations.

During his career he wrote over 750 contributions to the medical world of literature, including a the first textbook of Internal medicine published in 1892:   "The Principles and Practice of Medicine."  While he didn't know it at the time, it would end up being the last medical book written by just one person.

Osler would continue his work until his death in 1919, yet not before he became a legend in his own time.  His name was known by physicians throughout much of the world.  The debate had already begun as to whether he was the greatest physician to ever have lived.

Click here for more asthma history.

References:

1. "Sir William Osler At Seventy -- A Retrospect," The Journal of the American medical Association," 1919, Saturday, July 12, pages 106-108
2. Osler, William, "The Principles and Practice of Medicine," 1892, New York, pages 497-501
3. Bliss, Micheal, "William Osler:  A Life in Medicine," 1999, New York

Further readings:

1. Jackson, Mark, "Asthma: The Biography," 2009, New York, pages 211-12
2. Brenner, Barry E, ed., "Emergency Asthma," 1998, New York, pages 212-14

xTreatment of asthma 1901

Marcous Proust was a writer and a lifetime asthmatic.  The year 1901 was the dawn of modern asthma treatment and wisdom.  That was the year adrenaline and cortisone were just being discovered.

According to Mark Jackson the following are the medicines Proust used during his lifetime:

1. Strammonium cigarettes (same type of medicine as atrovent and spiriva)
2. Legras powders
3. Espic powders
4. Epinepherine (adrenaline)
5. Caffeine (same family of medicine as bronchodilator theophylline, not as strong
6. Carbolic acid fumigations
7. Escouflaire powder fumigations
8. Isolation -- cork lined bedroom (staying away from allergens)
9. Opium (relaxes breathing, mild bronchodilator)
10. Morphine (relaxes, mild bronchidilator)
11. Sea, lakeside and mountain resorts  (getting away from allergens, relax)

Jackson quotes Proust's journal entry to his mother:

"Yesterday after I wrote to you I had an asthma attack and incessent running of the nose, which obliged me to walk all doubled up and light asthma cigarettes at every tobacconist's as I passed, etc.  And what's worse, I haven't been able to go to bed until midnight, after endless fumigations..."  (August 31, 1901)

If the Internet were available to Mr. Proust I bet he'd be involved in an online asthma community as this blog is a part of.  While he didn't have the ability to blog, at least he wrote of his asthma experience in letters. 

Mr. Jackson is a professor at the Center for Medical History at the University of Exeter in England.  He's written books on asthma and articles on asthma and allergies and COPD.  I will link to some below so you can check them out at your liking.

Click here for more asthma history.

1. Divine Strammonium:  The rise and fall of smoking for asthma
2. Marcus Proust and the global history of asthma (slide show)
3. On Asthma:  A Biography
4. Allergies:  A history of the malady
5. The Oxford handbook of the history of medicine
6. Asthma timeline

1899 bronchitis triggers x

In 1899 Dr. Samuel Gee, in his article, "Bronchitis, Pulmonary Emphysema and Asthma, (The Lancet, March 18, 1889) defined bronchitis as a common disease that causes pulmonary catarrh and has the ability to strike anyone at any age.  It's inflammation that results in irritation of the mucous membranes and causes excessive secretions.

He mentioned as possible causes the following:

• Nitrous fumes
• Inhaled microbes
• Breathing dust
• Grass pollen
• Strong smells (odour of roses)
• Dust from molds
• Dust from fungi
• Influenza
• Typhoid fever
• Common cold
• Unexplained

Was this 19th glass factory poorly ventilated and cause asthma?

The idea that "dusty trades" caused breathing trouble was nothing new, Gee wrote.  He mentioned Ramazzini "two centuries ago developed several chapters of his book "De morbis artificum" to the diseases, chiefly pulmonary, which attend dusty trades."

Regarding dust he describes two types.  One is insoluble dust, such as those emitted from cotton mill smoke.  This type of smoke can cause cause bronchitis that is chronic and slow in developing.  It's a "mechanical irritant to the bronchial membranes." 

Yet he also observed that most people who work in trades where this type of dust is prevalent also smoke and drink alcohol.  So whether the bronchitis is a result of inhaling dust or these other habits is difficult to determine.

Insoluble dust would also include "dust from unclean and ill-ventilated rooms will be very likely to contain morbific microbes and the irritation of the air passages set up by inanimate dust will favour the operations of the many bacteria which are potent to cause bronchitis.  It obviously would be very improbable that these microbes should swarm in impure air and should not be found in the upper air passages of man.  And thus, as a matter of fact, our mouths, noses, and throats harbour many morbific microbes in a latent state; they are there awaiting a favourable opportunity for becoming active and virulent."

Inanimate dust would be your grass pollen which causes hay fever.  This condition results in inflammation (catahrr) of the nasal passages and this ultimately results in inflammation of the lungs (bronchitis). 

He mentions that strong smells, such that of roses, can cause bronchitis.  These flowers might also emit particles small enough to be inhaled.

Yet he also mentions one study where a doctor placed an artificial rose in the presence of a person, that this caused bronchitis.  From this "we have learned how large a part in the production of such a catarrh can be played by the power of imagination."

Dust from moulds and fungi are also considered inanimate dust.  Of interest is he also described two different types of sputum:  mucous and purulent.  He observed that some patients have both types in the spitting pot, and he surmised that "probably the different secretions come from different parts of the bronchial tract."

Today we might think of such patients as either suffering from chronic bronchitis caused by irritants and smoke, yet he may also be referring to asthma irritated by such substances.  Either way, Gee's observations were quite stunning given the knowledge of such diseases known at that time.

Reference:

Gee, Samual M.D., "Bronchitis, Pulmonary Emphysema, and Asthma," The Lancet, 1899, March 18, page 743-747

1839-1911: The infamous Dr. Gee

Samuel Gee (1839-1911)

"I'm punctual and expect the same from you," the philosophy professor said just after the bell rung.  "If you're not here when the bell rings you're not here at all in my eyes, and you'll fail my quizzes and tests."

By his 30 minute lecture on punctuality he scared us all, and earned our respect.  He also turned out to be an impeccable teacher who taught us a valuable lesson juxtaposing timeliness with success. 

While his name has since left my mind, the lesson he taught lives on.  I have this sense of urgency when it comes to being on time, although I wouldn't go as far to say I'm "punctual." 

I can't remember this teacher's name, yet I'm reminded of him as I delve into the life of Dr. Samuel Jones Gee who was well known for his punctuality. 

The Historic Hospital Admission Records Project described Dr. Gee this way: 

"His reputation as a teacher was second to none, and his punctuality the stuff of legend. He was leaving his house in a cab one day, when a patient detained him. As the conversation continued, the door of the vehicle swung open, hit a tree, and fell off its hinges. He insisted on carrying on to Bart’s minus the cab door, so that he would not be late." (1)

He was born in 1839 and developed a love for history, and because of this he became proficient in many languages, including Ancient Greek.  His ability to read and write in Greek would eventually benefit children around the world, as it allowed him to compare ancient accounts of diseases with what he observed during his own personal assessments and examinations on autopsy.

He attended college at University College School in London and studied medicine at the University College Hospital.  He impressed as a student enough to be hired as house surgeon at University College Hospital where he worked until 1865 when he earned his medical degree.

He was then hired at the Hospital for Sick Children, Great Osmond Street where he would eventually serve as pediatrician and pathologist.  He was passionate about learning about diseases and how to treat them, and he loved performing autopsies.

While his main job was working at the children's hospital, he also worked at St. Bartholemew's Hospital and managed to maintain a private practice.  A private practice back then involved the doctor traveling to the patient's home instead of the other way around as it is today.  So, while lucrative, it was a lot of work, and often quite risky.

He wrote 2 books and published 46 papers in St. Bartholemew's Hospital Report, with almost all of his writings on pediatric diseases -- which include asthma, bronchitis and consumption (tuberculosis).   HHARP mentions that one of the biggest complaints against him is he didn't write enough. (1)

What he is best known for is a lecture he gave in 1887 in which he gave the first modern day description of coeliac disease, a condition that affected many of the children he treated.  He described the condition this way:

“There is a kind of chronic indigestion which is met with in persons of all ages, yet is especially apt to affect children between one and five years old. Signs of the disease are yielded by the fæces; being loose, not formed, but not watery; more bulky than the food taken would seem to account for; pale in colour, as if devoid of bile; yeasty, frothy, an appearance probably due to fermentation; stinking, stench often very great, the food having undergone putrefaction rather than concoction".

He learned a lot about this disease by reading ancient accounts written by Aretaeus of Cappaocia who was a master clinician about 100 A.D.  Areteaus is known for providing some of the first descriptions for many diseases, such as pleurisy, diphtheria, tetanus, pneumonia, diabetes epilepsy and asthma.

He was also the first to describe the symptoms of coeliac disease, although he referred to it as coeliac diathesis.  Gee chose to respect Areteaus and referred to the condition as the coeliac affection.  Today we refer to the condition as coeliac disease. (2)

The condition causes it's victims to become pale, weak and appear to be wasting away, symptoms similar to tuberculosis.  Aerateaus believed it only occurred in adults, yet Gee recognized it could affect anyone, yet was most common among children aged 1-5, which was one of the main reasons Gee became so enthralled by the disease.

Gee was the first to differentiate between coeliac disease and tuberculosis, and he brought coeliac disease to the mainstream in the medical world.  He was also the first to suggest the cause and cure might be in the diet. 

Coeliac disease is similar to asthma in that neither disease causes any changes in their respective organs.  Of Coeliac disease Gee wrote, "Naked-eye examination of dead bodies throws no light upon the nature of the coeliac affection: nothing unnatural can be seen in the stomach, intestines, or other digestive organs."

Aerateus had a theory as to what caused asthma, and he likewise had a theory for coeliac disease.  He believed a "natural or indwelling" heat was needed for proper digestion, or "pepsis" as he referred to it.  Pepsis was the natural breaking down of food which occurred in the heat.  (2)

Aeratus explained that Coeliac affection was caused by a "chilling of the natural heat needed for 'pepsis.'"

Gee didn't agree with this, although he didn't pretend to know a cause or remedy.  A cause and treatment of the disease alluded the medical world until the 1950s when the condition was linked to the consumption of gluten in the diet.  Like asthma, coeliac disease is now considered an autoimmune disorders. 

Dr. Gee passed away in 1911, yet many of his publications are still available thanks to Google Books.  In our history of asthma and bronchitis I must make mention of him from time to time as so much of what he wrote is available to us thanks to Google.

Click here for more asthma history.

References:

1. "Dr. Samuel Jones Gee, "Historic Hospital Admission Records Project,  http://hharp.org/library/gosh/doctors/samuel-jones-gee.html
2.  Dowd, Brian, John Walker Smith, "Samuel Gee, Areteaus, and the Coeliac Affection," 1974, British Medical Journal, April 6, page 45
3.  Gee, Samuel, "Bronchitis, Pulmonary Emphysema, and Asthma,", Lancet, March 25, 1899, page 817

5000-50 B.C.: Egyptian priests/ physicians treat your asthma

So you are an Egyptian father of an Egyptian boy and you are convinced he is cursed by the god Isis.  You don't know what your son did, but he is outside leaning against a tree in order to breathe, and he's making loud wheezing sounds with each prolonged expiration.  You cannot bear to watch him suffer anymore, and so you send for help.  

It's possible that in the early days of Egypt you would have your child sit in the streets, and people who walked by would offer their medical advice; their diagnosis and medical treatment.  Some historians speculate this never actually occurred in Egypt, and others speculate it was an early transitional stage prior to the priest studying health at the temples, and maybe even prior to the transition of some priest into physicians.  (1, page 2)

Various temples were built where you could worship the various gods of Egypt, and specialized temples were built where you could worship the gods who specialized in health and healing.  These temples were places where the sick could sleep in the night, and a diagnosis and remedy would occur in the night, and in the morning a priest would interpret these dreams and visions. (1, page 2) (3, page 16)(8, page 19)

Patients who were too sick to leave their homes may send for a physician.  The president of the temple would determine the specialist best for the individual case, and that physician would be sent to the patient's home.  In this way, physicians made house calls.  (2, page 4) (4, page 17)

When he did so, he offered the following: (11, page 14)(12, page 13-15)

• Magic
• Draughts (potions)
• Blisters
• Poultices
• Plasters
• Powders
• Clysters
• Bleeding
• Pills made of dough
• Gargles
• Salves
• Inhalations
• Fumigations
• Supositories
• Incantations
• Amulets
• Hope
• Emetics
• Purgatives
• Diuretics
• Diaphoretics
• Cautery
• Surgery

The various drugs used were from animals (worms, snakes, insects, elephant, camel, crocodile, hyena), plants (radishes, onion), minerals (sulfur, zinc) and even humans excrements (feces, semen, saliva).  These were formulated in a variety of recipes that were prepared by the priests/physicians.  (12, page 15)

They would also prescribe good hygiene and a proper diet. (12, page 15)  They encouraged regular baths and purgings, and perhaps this was where the old adage came from: "prevention is better than the cure." People early on in history must have learned that nary a drug cured anything, and sometimes the drugs used made the person worse, or even killed him.  So the emphasis was placed on good hygiene and healthy eating, with the goal of keeping you healthy, and preventing you from getting sick.

Proof of this can been found in the Bible, when God told Moses to tell the people to follow a the laws set forth to prevent the spread of disease.  Moses, who probably studied under the tutelage of Royal Egyptian priest/physicians, encouraged Israelites to avoid diseased people, and not to touch corpes, and to wash and have good behaviors in order to prevent sickness. 

Common diseases treated were osteoarthritis, tuberculosis, rickets, and syphilis. (12, page 15)  Modern evidence from mummies suggests they also treated atherosclerosis. Although their limited knowledge of anatomy prevented them from knowing about these diseases, they basically observed and treated the symptoms, which to them were caused by the gods, and, if not treated by the powerful magic of the priests/ physicians, would result in death.

The god Thoth communicated with an ancient priest, perhaps Imhotep, and Thoth provided Imhotep with all the wisdom of the gods.  The god invented all the arts and sciences, including a written language, medicine, and laws.  Thoth provided Imhotep with all this wisdom, and he carved them into pillars of stone, creating 42 books, the last six of which containing all the medical wisdom of the gods, and the laws regulating their practice.  (2, page 3)(3, page 14)

The ancient Greeks called Thoth Hermes Trismegistus, and therefore the books he wrote are often referred to as the Hermatic books.  A specialty of priests became the scribes, and they were among the wisest and most revered priests in all of Egypt.  Scribes transcribed the Hermatic books so they could be visible in all temples of the gods of health and healing, and so these temples became the places of learning among the priesthood.

Thoth ultimately taught the priesthood to make paper out of stalks of papyrus, and scribes were able to transcribe the Hermatic text onto large scrolls, and in this way every physicians could now have his own copy. When called upon to visit the sick, he must have taken his scroll with him, perhaps carrying it with him in his medical bag.

While temples to the gods were places of worship and healing, many were also were also the centerpieces of places that acted like our modern universities, complete with schools, libraries, laboratories, papyrus/paper factory and boarding houses.  These were places of instruction for not just priests and physicians, but astronomers, mathematicians, and a variety of other professions. Some of the original and most famous temples/ universities were situated at Memphis, Thebes and Heliopolis, Sais, and Chennu. (3, page 16)(8, page 19)(11, page 9)

The higher class of priests at these schools studied the first 36 books, and others the last six*.  Perhaps it was at such schools where Egyptian priests/ physicians developed such beliefs as life "should be indefinitely prolonged, unless someone or something caused death, such as a spirit, or the soul of a dead man, which cunningly entered a dead person," according to Sandwich. (1, page 2)(9, page 25)

Perhaps it was at these temples that a greater understanding of diseases was speculated upon, and the realization was made that many diseases were associated with dirtiness, and that some diseases were spread from person to person.  It's for this reason, perhaps, that people contaminated with certain diseases, such as the lepers, were cast from society and you were warned to stay away from them.

The priesthood, then, learned the importance of cleanliness in maintaining good health, and it's from here where circumcision became standard practice, along with regularly scheduled bathing, the wearing of clean clothing, and similar such rituals.  It is also from here that diet and drugs were incorporated into the medical regime "to counteract the disorders which the strange being had produced in the body," according to Fleming Sandwich in his 1905 book. (1, page 2)

Such cleanliness must have been rather successful at keeping the Egyptians healthy.  William Hudson Garrison, in his 1922 history of medicine, quotes Aristotle from his Politics, as saying: "They purge themselves every month, three days in succession, seeking to improve health by emetics and clysters; for they suppose that all diseases to which men are subject proceed from the food they use. And, indeed, in other respect, the Egyptians, next to the Libyans, are the most healthy people in the world, as they, on account of the seasons, because they are not liable to change." (5, page 51)

Likewise, Plinio Prioreschi,  in his 1991 history of medicine, explains that Egyptian medicine gained a "great reputation" as noted by the following passage from Homer's Odyssey: (10, page 257)

...for there (in Egypt) the earth, the giver of grain, bears the greatest store of drugs, many that are healing when mixed, and many that are baneful; there every man is a physician, wise above human kind... 

Alexander Wilder, in his 1901 history of medicine, says that "the skill and learning of physicians of Egypt made them famous in the neighboring countries."   In one example, "the Prince Bakhtan (Bashan) sent an embasy to Ramases XII for medical aid for his queen's sister."  Ultimately "the pastaphori and physicians bearing a receptacle of the divinity... the mission was successful; the princess speedily recovered, and the god received the glory." (11, page 15)
-------------------------
By the height of Egyptian civilization, society evolved into six orders:  (4, page 32)

• Kings and princes 
• Priests
• Soldiers
• Shepherds
• Laborers
• Artisans.  

Of these six orders, only the kings and princes were privy to their own physicians.  

Most of these orders were divided into various castes, with various of the priesthood being chosen to specialize in the various wounds and diseases and these became the caste of physicians. Members of this caste becoming "the most respected and the most powerful" members of the society. The caste "was a depot of the laws, science and religion."  (2, page 32)

 Of these physicians, the great Greek historian Herodotus (484-425 B.C.) once wrote: (5, page 50-51):

"The art of medicine is divided among them: each physician applies himself to one disease only, and not more. All places abound in physicians; some physicians are for the eyes, others for the head, others for the teeth, others for the intestines, and others for internal disorders."

Each physicians specialized in one disorder, such as:

• Disorders of the head
• Disorders of the eyes
• Disorders of the rectum/ anus
• Disorders of the teeth
• Disorders of women
• Experts in child bearing
• Experts in surgery (surgeons)
• Internal medicine (treat asthma-like symptoms, cancer, upset stomach, etc.)

Homer even notes the following regarding Egyptians:

...in the land where the fruitful soil bore abundance of herbs potent for good or evil, nearly everyone was, so to speak, a doctor or a descendant of Paeon and learned among the men. (8, page 18)

Paeon (Paean) was the physician to the gods.  By Homer's reference, historians surmise that as medical knowledge was specialized, many of the commoners became knowledgeable in medicine, each becoming a pseudo-physician.  As our modern day homes, many people had their own medicine chests, and had the ability to treat basic cuts and scrapes, and ailments like the common cold.

When wounds were severe, or as diagnosis and treatment reached beyond the commoners scope of knowledge, only then would the greater expertise of a priest or physician be sought.

The classes of priest/ physicians were divided this way:  (3, page 16-17)(2, page 3-4)(7, page 13-14)

1. Chief Priests:  Also referred to as Sages, Soothsayers, Image Bearers, Magi, sorcerers, wise men or magicians.  These were the wisest of the priests/ physicians, and they were privileged to all the knowledge of the gods, and hence were responsible for reading the first 36 books of the Hermetic books. They were physicians of the "higher sciences."  These priests/physicians were responsible for "conjurations, dissolving the charms of the gods by prayer, interpretations of the revelations received by the sick during incubation in the temples."  (3, page 16-17) They were more like the medicine men of the primitive world, "disolving the charms of the gods by prayer... magic and divination."  (2, page 4)  They were even mentioned by Moses "in the 7th and 8th chapters of Exodus, under the names of wise men, the sorcerers, and magicians, of Egypt, whom Pharaoh called in to rival the miracles performed by Moses." (7, page 13)
2. Pastaphori: The lower class of priests were responsible for studying the last six of the Hermetic books, and were responsible for visiting the sick and treating them.  They were your prototypical physicians, or ordinary physicians devoted specifically to medicine and the art of healing. Each of these physicians/ priests specialized in a certain ailment, such as internal medicine, dentistry, rectum, etc. They treated "anatomy, pathology, pharmacology, opthalmology, and gynecology." This profession probably morphed from the need of physicians to leave the temples, especially as medicine (particularly rational/civilized) evolved. 
3. Military physicians:  They essentially were Pastaphori who followed the military, and mainly were experts in treating battle wounds with salves, casts, splints, incantations, etc. Each of these also specialized.
4. Veterinary:  They specialized in health and healing of animals.  They specialized as well, as your cattle doctors, fowl doctors, etc. 

According to William Hamilton in his 1831 history of medicine, only certain priests were privileged to become physicians, and "the office of these priests was hereditary and their privileges were exclusive; as the son trod with unvarying servility in the footsteps of his father."  (7, page 13)

Physicians were free from the bondage of taxes, were paid by the collective, and profits belonged to the temple. The only obligation of the patient was to provide gifts, which sometimes included models of the organ fixed or operated on (such as an arm or leg), and these were kept at the temples as mementos, perhaps, of the healing powers of the gods. Likewise, "during war, or in the case of anyone falling ill upon a journey, the doctors were bound to render help gratis," (4, page 17) (9, page 25)(11, page 10)

Hamilton says that "Improvement to medical knowledge was effectually arrested by the penal discouragement of every attempt to deviate from the canons of practice laid down in the volumes ascribed to Thouth (Thoth); and the interests of the priests led to the perpetuation of the popular delusion respecting the cause of disease, (7, pages 13 and 14)

According to the Diodorus, diseases were diagnosed by the position of the patient in bed, (6, page 25), and treatment was standard, or based on your symptoms, as noted by Bradford: (1, page 6)

The Egyptians paid strict attention to dietetic rules; they thought that the majority of diseases were caused by indigestion, and excess in eating. They practiced abstinence and used emetics. They had a considerable knowledge of Materia Medica (the pharmacopoeia) and used many drugs in the cure of the sick. They were somewhat skilled in operative surgery. They practiced castration, lithotomy and amputations

So Egypt had a plethora of physicians who specialized in the various wounds and ailments that plagued Egyptian society.  Such specialization was both bad and good.  It was bad when you were sent a specialist who didn't specialize in what plagued you, such as if a physician who specialized in disorders of the rectum was sent to treat your son's dyspnea.

It was good when your specialist had knowledge of internal disorders, and had access to remedies that contained opium or belladonna that had magical abilities to sedate him so he can better deal with his agony.

While preparing the ingredients, he may he might site the following incantation: (3, page 23)

"May Isis heal me, as she healed Horns of all the ills inflicted upon him when Set slew his father, Osiris. 0 Isis, thou great enchantress, free me, deliver me from all evil, bad and horrible things, from the god and goddess of evil, from the cod and goddess of sickness, and from the unclean demon who presses upon me, as thou didst loose and free thy son Horus" 

As you can see, the medical profession among "the ancient Egyptians hold the honor of being the first people to cultivate medicine as a science," and that this "medicine was closely associated with the mythology of Egypt."  (2, page 1)

Surely we might look at Egyptian medicine, as well as medicine of any ancient society, and think to ourselves:  this is quackery.  Yet these ancient societies probably benefited more from the magic of incantations and  prayers, or by the gentle touch of a palm on the shoulder, than from any other form of medicine.  As noted by Henry Sigerist in his 1951 book, "A History of Medicine: Primitive and Archaic Medicine: (13, page 280-1)

The oral rite was all important.  The correct choice of words to frighten a spirit, to enlist the help of the gods, the intonation probably also in which a spell was recited or sung, this all must have had a profound effect upon the patient.  We know the power of suggestion and know how highly responsive religious individuals are to such rites.  I should not be astonished if the sorcerer with his spells had had as better results in many cases than the physician with his drugs.  Magician and priest were able to put the sick in a frame of mind in which the healing power of the organism could do its work under the best conditions.  They gave him peace and confidence and helped him to readjust to the world from which disease had torn him.(13, page 280)

Sigerist also writes the following:

The manual rites performed in the course of an incantation appear in infinite variety from teh simplest to the most elaborate and complicated.  the rite may have consisted of nothing but putting one's hand on the patient, the classical gesture of protection so familiar to us from the Bible.  After having exorcised a demon the magician said: 'My hands are on this child, and the hands of Isis are on him, as she puts her hands on her son Horus.'  Or the magician held his seal over the child and such as seal was obviously a powerful fetish: 'My hand is on thee and my seal is thy protection'  (13, page 281)

There may have come a day when "drugs were prepared and given without incantation and this was the moment when magic and medicine separated, when physicians and magician-priest became different individuals." (13, page 280  Yet the priest of the ancient world, whether using magic words or herbal remedies, would have known of the power of suggestion, and perhaps, just perhaps, never ceased to use the power of magical words, amulets, talismans and gesticulations.

So your son continues to struggle with his breathing, and you decide you need to seek help for him.  You summon a priest, and within a few hours a priest/physician is humming incantations while your son is inhaling fumes from herbs tossed on the fire. Perhaps by the doctor's appearance alone your boy is able to relax, allowing nature to heal him over time.

*Along with physicians, judges, mathematicians, astronomers, etc., were also educated at such schools. (8, page 19)

Further reading:

• 5000-50 B.C.: Asthma in Ancient Egypt: the Bible
• 5000-50 B.C.: Egyptian gods of healing
• 5000-50 B.C.: Asthma in Ancient Egypt, the Eber Papyri
• 2700 B.C.: Imhotep invents medcine
• 2700 B.C.: The Hermetic Books 
• 2700 B.C.: The birth of rational medicine
• 800 B.C.-800 A.D.: Asclepius will heal your asthma

 References:

1. Sandwich, Fleming Mant, "The medical diseases of Egypt, part I," 1905, London
2. Bradford, Thomas Lindsley, "Quiz questions on the history of medicine: form the lectures of Thomas Lindsley Bradford, M.D," 1898, Philadelphia
3. Baas, Johann Herman, author, Henry Ebenezer Sanderson, translator, "Outlines of the history of medicine and the medical profession," 1889, New York
4. Renouard, Pierce Victor, "History of Medicine: From it's origin to the 19th century," 1856, Cincinnati, Moore, Wistach, Keys and Co., page 26, chapter 1, "Medicine of the Antique Nation."
5. Garrison, Fielding Hudon, "An introduction to the history of medicine," 1922, Philadelphia and London, W.B. Saunders Company
6. Dunglison, Robley, author, Richard James Dunglison, editor,  "History of Medicine from the earliest ages to the commencement of the nineteenth century," 1872, Philadelphia, Lindsay and Blakiston
7. Hamilton, William, "The history of medicine, surgery, and anatomy, from the creation of the world to the commencement of the nineteenth century," 1831, volume I, London, Henry Colburn and Richard Bentley
8. Puschmann, Theodor, translated by Evan H. Hare, "A history of medical education from teh most remote to the most recdent times," 1891, London, H.K. Lewis
9. Puschman, Theodor, translated by Evan H. Hare, "A history of medical education from the most remote to the most recent times," 1891, London, H.K. Lewis
10. Prioreschi, Plinio, "A History of Medicine," Volume 1: Primitive and Ancient Medicine," 1991, Edwin Mellen Press, Chapter IV: Egyhptian Medicine, page 257.  Reference noted by author is as follows:  Homer, "Ocyssey, IV, 229-232, Translation by A.T. Murray.
11. Wilder, Aleander, "History of Medicine," 1901, Maine, New England eclectic Publishing
12. Osler, William, "Evolution of Modern Medicine: a series of lectures at Yale University to the Silliman Foundation in April 1913, 1921", New haven, Yale University Press
13. Sigerist, Henry E, "A History of Medicine: Primitive and Archaic Medicine," volume I, 1951, New York, Oxford University Press

1851: Dr. Salter, the famous asthma doctor

Figure 1 -- Dr. Henry Hyde Salter.

As a kid he suffered mightily from asthma, and when he grew up he made his disease the focus of his life.  He wrote a book that became the most famous asthma book of his era. His name was Dr. Henry Hyde Salter, the famous asthma doctor.

He was born on November 2, 1823. Within only a few weeks of his birth he suffered a bout of whooping cough that ultimately lead him to a lifetime of suffering from asthma. (1)

His dad was a prominent surgeon.  His grandpa, uncle and several members of his family were also physicians.  So it wasn't surprising that, after graduating from the University of London, he entered King's college to study medicine. (1)

He earned his medical degree in 1851 and soon opened a medical practice.  It probably didn't take him long to realize he had a special sort of empathy towards his asthmatic patients, particularly asthmatic children.

From a photograph of an asthmatic, whose disease

dated from whooping-cough at three months old.

(One might wonder if this is a photo of a young

Dr. Salter.) (6, page 115)

In 1851 he became assistant physician at King's College Charing Cross Hospital, and in 1852 he became assistant physician to Robert Bentley Todd (1816-92) in New York.  He sat in on Todd's lectures and took copious notes "almost verbatim," which were published in the Medical Gazette and ultimately this "added much to Dr. Todd's reputation. (1)

Likewise, in 1851, he became assistant-editor of the "Encyclopedia of Anatomy and Physiology."  He wrote articles on the tongue and pancreas, and he read and edited the entire collection.  (1)

In 1854 he returned to King's College where he lectured in physiology, physiological anatomy and medicine for the next 12 years.  His efforts as a writer, lecturer and physician earned him a spot as the youngest member of the Royal College of Chest Physicians in 1856 at the age of 33.  He gave a lecture to this group on dyspnea in 1866. (1)

Yet it was asthma that was his "special interest" in many of his research and study projects. (2) He gave many lectures, most about diseases of the thorax -- and asthma.  (5)

Dr. Salter's special interest in asthma gave him a unique inside take on what it was like to have asthma. This, coupled with his exemplary skill at writing, made him the ideal person to write on the subject.

In his book he provided some of the best and most vivid descriptions of asthma up to that time, as shown here:

"But not only is asthma not an uncommon disease, but it is one of the direst suffering; the horrors of the asthmatic paraxysm far exceed any acute bodily pain; the sense of impending suffocation, the agonizing struggle for the breath of life, are so terrible, that they cannot even be whitnessed without sharing in the sufferers distress." (6, page 17)

His description of the suffering was likewise vivid.  He wrote:

 "With a face expressive of the intensist anxiety, unable to move, speak, the head thrown back between elevated shoulders, the muscles of respiration rigid and tightened like cords, and tugging and straining for every breath that is drawn, the surface pallid or livid, cold and sweating -- such are the signs by which this dreadful suffering manifests itself." (6, page 18) 

As well as was his overall description of the asthma paroxysm.  He wrote:

But the dyspnoea of asthma tells a plainer tale than this; it tells us not only what it is not, but what it is. It gives the most positive evidence of narrowing of the air-passages. The asthmatic's breathing is what our forefathers called "strait," what we call " tight;" he feels as if a weight were on his sternum, as if his chest were compressed, as if a cord bound him, as if it would be the greatest relief to him if some one would cut his breast open and allow it to expand; he rushes to the window to get air, he cannot tolerate people or curtains about him, his clothes are loosened, and all the muscles of respiration tug and strain their utmost to fill his chest. But he can neither get air in nor out, he can neither inspire nor expire—his respiration is almost at a dead lock; he cannot blow his nose, ean hardly cough or sneeze, cannot smoke a pipe, and if his fire is failing, cannot blow it up; he has hardly air enough to produce the laryngeal vibrations of speech. (6, pages 37-38)

He even went as far to describe what life was like for an asthmatic between attacks.  He wrote:

"And even in the intervals of health, the asthmatics sufferings do not cease; he seems well, he goes about like his fellows and among them, but he knows he is altogether different; he bears about his disease within him wherever he goes; he knows he is struck... he is conscious that he is not sound... he only knows that a certain percentage of his future life must be dedicated to suffering; he cannot make engagements except with a proviso; and from many of the occupations of life he is cut off; the recreations, the enjoyments, the indulgences of others he dare not take; his usefulness is crippled, his life is marred; and if he knows anything of the nature of is complaint, he knows that his suffering may terminatein a closing scene worse only than the present." (4, page 17, 18)

Any person who ever suffered from an attack of asthma, or ever witnessed one, could easily relate to what Salter described.  It was such exemplary asthma prose that proved to his readers that he knew what he was writing about.  It was such that made him to be the famous asthma doctor.

After years spent suffering, and years spent studying his patients, and performing interviews and autopsies, he put his best asthma knowledge together during the 1950s in a series of articles that were published in medical journals throughout the decade.  Each article was ultimately turned into a chapter in his 1864 book "On Asthma:  It's Pathology and Treatment."

During the last four years of his life his asthma took a turn for the worse.  During the night he'd spend time leaning against the bed post with his shouders hunched while smoking datura leaves. During the day he ate lightly, and continued to work as a physician and to give lectures.

In 1871 he became thinner and weaker and was diagnosed with typphoid fever.  Yet ultimately it was discovered he developed a lung abcess and passed away on August 30, 1871, at the young age of 48.

Dr. Salter's book is referenced in nearly every article, every chapter, and every book on asthma for the rest of the decade.  Even the great Dr. William Henry Osler referenced Dr. Salter when he wrote his textbook for medical students.

Further reading:

• 1864:  Dr. Salter offers proof asthma is nervous
• 1864: Dr. Salter proves nervous theory of asthma (1/5/16)
• 1864: Dr. Salter disproves ancient asthma theories (12/30/14)
• 1864: Dr. Salter's Asthma Features (2/14/14)
• 1864: Dr. Salter's Varieties of Asthma (2/20/14)
• 1864  Dr. Salter's asthma triggers (2/27/14)
• 1864: Dr. Salter's asthma signs and symptoms (3/6/14)
• 1864: Dr. Salter's Consequences of asthma (3/13/14)
• 1864: Dr. Salter's Asthma Remedies (3/27/14)
• 1864: Dr. Salter's prognosis for asthmatics (4/10/14)

Click here for more asthma history.

References:

1. "The Late Henry Hyde Salter," Medical Times and Gazette, Sept. 13, 1871. 
2. McCulough, David, "Mornings on Horseback," 1981, New York
3. Sakula, Alex, "Henry Hyde Salter (1823-71) a biographical sketch," Thorax, 1985; 40; pages 887-888.
4. Salter, Henry Hyde, "On Asthma:  Its Pathology and Treatment," 1861, London, Philadelphia
5. Kidd, G.H. Dr., "On the pathology of Asthma," Dublin Quarterly Journal of Med. Science," 1861, May,
6. Salter, Henry Hyde, "Asthma: It's Pathology and Treatment," 1864, Philadelphia, Blanchard and Lea