460-370 B.C.: What did Hippocrates think about asthma?

Hippocrates is given credit as the author of the Corpus,
and therefore as the father of medicine.  The truth is,
however, that the figure in the bust here is probably
 a composite of what a typical physician would look like
around 400 B.C. The name Hippocrates has become
synonymous with the transformation of medicine that
occurred during this era of history.

As we peruse ancient writings we find many references to asthma, or at least asthma-like symptoms. The ancient Egyptians, Greeks, Chinese and even Japanese all recorded asthma-like events and the remedies to go along with them.  Yet it was Hippocrates,  particularly in his Corpus Hippocraticum, who made asthma a household name.

Please not here that Hippocrates was an actual physician, although his name is generally attributed to the medical wisdom of this era.  So as historians contribute the birth of medicine to Hippocrates, they are actually referring to the accumulated wisdom of Hippocrates and all of his immediate ancestors.

As far as we know, the first known person to use the term was Homer in his epic poem the Iliad, which was written about 800 B.C. Homer used it to denote gasping or air hunger that occurred after physical exertion or during the process of dying.

As was typical of the ere of philosophers in ancient Greece, Hippocrates had questions and he yearned for answers.  He wanted to know about all diseases, their causes and cures.  With limited ability to inspect the insides of the human body, his anatomical wisdom was limited.

He had no means of associating symptom seen outside the body with changes that occurred inside.  He therefore was forced to use reason to answer his questions about diseases such as epilepsy, dropsy, colds, catarrh, and asthma.  These answers were called theories.  They may seem quite spurious to the modern reader, although to the ancient Greeks they were quite logical.

So when Plato, and then Hippocrates, used the term asthma, they were pretty much denoting a symptom rather than a disease.  Plato used the term to denote short, gasping breaths by those wounded in battle or those who were exhausted after running from an enemy. Hippocrates used it in a similar way, although his definition was a bit more refined.

For example, Hippocrates defined the various forms of shortness of breath:

1. Dyspnea: Shortness of breath
2. Asthma (asthmata): Severe shortness of breath
3. Orthopnea: So short of breath you have to sit up to breathe (a bad sign)
4. Tachypnea: Rapid respiratory rate

He was the first to define asthma as a medical term. Since he didn't understand anatomy, asthma became a rubric term, an umbrella term, for severe breathing difficulty.  So from this point on if you were short of breath you had asthma, regardless of the natural cause.

To Hippocrates, like headache and fever, asthma was merely a symptom.

While this was a very vague definition, it was a start.  Later, as new wisdom was learned, the definition evolved.  Diseases that did not fit under the newer definition were extricated from under the umbrella term asthma to become disease entities of their own.

The first two examples were probably peripneumonia and phthisis, two diseases we now refer to as pneumonia and tuberculosis.  Diseases extricated after the death of Hippocrates were scoliosis, cardiac asthma (heart failure), kidney asthma (kidney failure), bronchitis and emphysema.

It's also interesting to note that diseases that caused curvature of the spine, such as scoliosis, were also considered as asthma.  They caused dyspnea because they resulted in less space for the lungs in the chest.  As these people age it can lead to dyspnea and even an early death.  In fact, Hippocrates mentioned this in one of his Aphorisms:

Such persons as become hump-backed from asthma or cough before puberty, die. (17, page 141

Hippocrates also observed redness and inflammation inside the nose, mouth and eyes of some patients, and he referred to this as catarrh.  By this he observed signs of the common cold, bronchitis, and allergies.

He wrote a treaties "Of Epilepsy."  Prior to his time the condition was referred to as the sacred disease because it originated from the anger of the gods, most likely Cybele, Neptune, Proserpine, Apollo, Mars, and Hecate.  Hippocrates tried to explain that epilepsy was "nothing more sacred or divine than an other." (11, pages 201-203)

Hippocrates believed that instead of being a divine disease, epilepsy was caused had a natural cause, which started by an increase of phlegm in the brain that ultimately made it's way to the veins and impeded flow of pneuma to the brain. He said:

This malady, then, affects phlegmatic people, but not bilious. It begins to be formed while the foedtus is still in utero. For the brain, like the other organs, is depurated and grows before birth. If, then, in this purgation it be properly and moderately depurated, and neither more nor less than what is proper be secreted from it, the head is thus in the most healthy condition. If the secretion (melting) from the whole brain be greater than natural, the person, when he grows up, will have his head diseased, and full of noises, and will neither be able to endure the sun nor cold. (14)

Hippocrates, like Greek physicians before him, believed asthma was epilepsy of the lungs.  He believed that air (with pneuma) was inhaled and flowed through the body by means of the veins.  It flowed to the heart and brain and other organs in order to keep them functioning.

Hippocrates said:

By these veins we draw in much breath, since they are the spiracles of our bodies inhaling air to themselves and distributing it to the rest of the body, and to the smaller veins, and they and afterwards exhale it. For the breath cannot be stationary, but it passes upward and downward, for if stopped and intercepted, the part where it is stopped becomes powerless. In proof of this, when, in sitting or lying, the small veins are compressed, so that the breath from the larger vein does not pass into them, the part is immediately seized with numbness; and it is so likewise with regard to the other veins. (19)

He also believed that the humor phlegm was made in the brain.  When it was in excess it could flow to the heart and lungs, thus causing asthma. (9, page 61-62) (10, pages 14-15)

He said:

But should the defluxion (flow of humors) make its way to the heart, the person is seized with palpitation and asthma, the chest becomes diseased, and some also have curvature of the spine. For when a defluxion of cold phlegm takes place on the lungs and heart, the blood is chilled, and the veins, being violently chilled, palpitate in the lungs and heart, and the heart palpitates, so that from this necessity asthma and orthopnoea supervene. For it does not receive the spirits as much breath as he needs until the defluxion of phlegm be mastered, and being heated is distributed to the veins, then it ceases from its palpitation and difficulty of breathing, and this takes place as soon as it obtains an abundant supply; and this will be more slowly, provided the defluxion be more abundant, or if it be less, more quickly. And if the defluxions be more condensed, the epileptic attacks will be more frequent, but otherwise if it be rarer. Such are the symptoms when the defluxion is upon the lungs and heart; but if it be upon the bowels, the person is attacked with diarrhoea.  (14)

Mervyn J. Eadie and Peter F. Bladin, when writing about the sacred disease of Hippocrates, explained the thinking of Hippocrates regarding the cause of epilepsy and asthma.  They said:

He (Hippcrates or the Hippocratic writer) considered the disorder (epilepsy) in the following way:  during normal prenatal development the brain underwent a process of purification as it grew in the womb.  If this purification process did not occur, the sufferer was likely to grow up with a diseased head.  Purification of the brain might still occur after birth.  If so, phlegm would then be secreted into the upper respiratory tract or lost from the body in discharged from ulcers.  If such purification, which should have got rid of phlegm from the brain, did not occur at some state, the sufferer would be prone to experience epileptic seizures. When a 'defluction' of the retained phlegm from the brain occurred, the phlegm might go to the heart and chest to cause palpations, asthma, chest disorders and possibly spinal deformity. If it went to the abdoment it caused diarrhoea.  (18, page 94)

If the cold phlegm was not able to make it into the lungs or abdomen, it entered the veins where it obstructed the flow of pneuma.  When the pneuma was obstructed this could result in seizures, but it could also result in "interruption of inspiration."  (18, page 94)

When the pneuma was unable to make it back to the brain this caused "interruption of speech and intellectual functions, and loss of power in the hands.  The palpating veins affected the lungs to cause froth to emerge from the mouth.  The violent suffocation might cause involuntary defaecation, as the liver and stomach ascended to the diaphragm and the mouth of the stomach closed. (18, page 94)

So asthma was basically a symptom of a greater problem which ultimately originated from too much phlegm being created by the brain.

In his "Airs, Waters, and Places," he said:

...infants are subject to attacks of convulsions and asthma, which they consider to be connected with infancy, and hold to be a sacred disease (epilepsy). (14)

Hippocrates said:

Infants are subject to attacks of convulsions and asthma, which they consider to be connected with infancy, and hold to be a sacred disease (epilepsy) (13, pages 9, 11)

From these two passages many experts speculate Hippocrates observed that epilepsy and asthma were common in infants.

He also alluded to asthma as being "convulsive" or spasmotic in nature.  In other words, he alluded to what would later be referred to as the spasmotic theory of asthma, or that asthma was caused by "convulsions" or spasms in the lungs.

Paul Ryan, in his 1793 book "Observations on the history and cure of asthma," said:

It appears extremely probable that Hippocrates, in placing asthma... in contradistinction with pleurisy and peripneumony (pneumonia), must have had in view the spasmotic kind... he says that old men are very subject to difficult breathing, cough, and catarrhs and defluxion on the lungs. (9, pages 59-60)

After Hippocrates wrote about the disease as spasmotic in nature, later physicians suspected asthma was a nervous disorder.  It wouldn't be until the early 19th century that it was proved that Hippocrates was right all along, at least about asthma being spasmotic in nature.

Although others speculate that since asthma was associated with epilepsy, and that it was caused by defluxion of humors from the brain, that it was indeed a mental illness, or a nervous disorder.

Bernardino Ramazzini said Hippocrates was probably the first to describe asthma as a hazard of certain occupations.  Although the idea was scrapped until Ramazzini picked it up in the 17th century, and then scrapped again until the middle of the 20th century.

Hippocrates also accurately described asthma as a disease inherited along the family line, and while this was supported by an occasional physician along the historical timeline,  it wasn't proved until hundreds of years after the fall of Greece and Rome.

Despite his possible association of asthma with spasms in the lungs, he did not, as a general rule, associate diseases with specific organs.  This would be the accomplishment of a great physicians born into the 2nd century after the birth of Christ by the name of Galen.

Hippocrates speculated that diseases were caused by certain changes in the winds, changes in temperature, or by the ingestion of certain foods. These caused a disunity within the body of the four qualities and humors, thus causing disease.

For example, some aphorisms describe asthma as occurring commonly in the middle ages, when the body functions start to slow down and cool, and in the fall season, when the temperatures start to cool.

Image of Hippocrates (12, title page)

Hippocrates said:

In autumn many maladies which occur in summer prevail, besides quartan and erratic fevers, affections of the spleen, . dropsy, consumption, strangury, dysentery, sciatica, quinsey, asthma, volvulus, epilepsy, mania, and melancholy. (12, page 59)

He added:

To persons somewhat older, affections of the tonsils, incurvation of the spine at the ver- tebra next the occiput, asthma, calculus, round worms, ascarides, acrochordon, satyriasmus, struma, and other tubercles (phymata)^ but es- pecially the aforesaid. (16, page 134)

Ryan added:

...that the asthma mentioned by him was of the spasmotic kind, and that he considered cold and moisture its principle causes.  At least it must be allowed that this was his opinion with regard to the disorder in children. (10, page 62)

In review, he believed the following was true of asthma:

• It was related to the epileptic resonse
• It was hereditary
• It was convulsive or spasmotic in nature
• It was caused by an abundance of cold phlegm flowing from brain to lungs
• It was common in infants
• It was common in the elderly
• It was caused by changes in seasons, such as from summer to fall (cooler air)
• It was caused by some occupations
• It is common in phlegmatic persons

It is generally believed that Hippocrates redefined the mode of assessing and diagnosing patients.  He made a thorough examination of the patient and his surroundings.  He assessed the patient's breathing both by observation with his eyes and with his ears.

He listened to his patient's breathing, took his respiratory rate, felt for a pulse, felt his skin for fever, observed perspiration and sweating, inspected his urine, inspected his sputum, among other things.

He may even have shook his patient in order so that he could hear if he had increased phlegm in his chest, a procedure called succussion.

He would ask the patient questions:

• Have you been around anything new lately?
• Is there a history of this in your family?
• Is anyone else sick in your family? In your city-state?
• Has there been a change in winds recently?
• What is your job?

If the patient was unable to answer these questions, he would ask friends and family members.  The answers to these questions may determine what changes occurred to the humors inside the patients body.  This would then determine the cause and the cure.

If the patient was diagnosed with asthma, the cures were the same as for any basic ailment, and were generally meant to assist nature in the healing process.  Such remedies included:

• Bathing
• Breathing purified air
• Getting plenty of sleep
• Eating a specific and healthy diet
• Getting exercise

He also believed asthmatics should avoid whatever was thought to exacerbate it, and this may have been the best remedy of them all.  

If asthma did not improve with the basic remedies, only then would Hippocrates recommend other remedies, such as:

• Massage
• Glass of wine or Mandragora as a sedative
• Draught of white hellabore to induce a good purging to cleanse the system. 
• Bleeding (rarely)
• Inhaling herbs

Asthma historian Mark Sanders said that another remedy he might have prescribed was inhaling the fumes of various herbs "boiled with venegar and oil" through a tube.  (7)

He provided medicine with the first viable description of asthma and the first simple remedies.  His remedies were mainly palliative in nature, offering the patient hope as he waits for the asthma episode to dissipate.

Click here for more asthma history.

References

1. Prioreschi, Plinio, "A history of medicine," vol II: Greek Medicine, chapter five, "Hippocrates," 2nd ed., 1996, NE, Horatius Press, 201-5
2. Sigerist, Henry E "A History of Medicine," vol I, "Primitive and Archaic Medicine," 1951, New York, Oxford university Press
3. Withington, Edward E, "Medical history from the earliest times: a popular history of the healing art," 1894, London, Aberdeen University Press
4. Watson, John, "The Medical Profession in Ancient Times," 1856, New York,
5. Fourgeaud, V.J, "Historical Sketches:  Galen," Pacific Medical and Surjical Journals, ed. Fourgeaud and J.F. Morse, Vol VII, San Franskisco, J Thompson and Co, 1864, page 22-29
6. Meryon, Edward, "The History of Medicine," 1861, Chapter II, "The Greek System of Medicine, From the Time of Hippocrates to the Christian Era."
7. Sanders, Mark, "Inhalation Therapy: An Historical Review," Primary Care Respiratory Journal, 2007, 16 (2), pages 71-81
8. Cotto, Bob, "Who Discovered Asthma: Hippocrates or Galen?" ezinearticles.com, http://ezinearticles.com/?Who-Discovered-Asthma-Hippocrates-Or-Galen?&id=1381520, accessed 11/1/13
9. Ryan, Michael, "Observations on the history and cure of the asthma:; in which the propriety of using the cold bath in that disorder is fully considered," 1793, London, Paternoster - Row
10. Jackson, Mark, "Asthma: The Biography," 2009, London, Oxford University Press
11. Hippocrates, "On Epilepsy," epitomised from the original Latin text by John Redman Coxe, 1846, "The Writings of Hippocrates and Galen," Philadelphia: Lindsay and Blakiston
12. Hippocrates, "The aphorisms of Hippocrates," translated by Thomas Coar, 1822, London, Printed by A.J. Valpy, Red Lion Court, Fleet Street
13. Hippocrates, "Airs, Waters and Places," translated by eminent scholars, 1881, London, Messrs Wyman and Sons 
14. Hippocrates, "The Sacred Disease," translated by Robert Maynard Hutchins, "Great Books of the Western World: Hippocratic Writings on the Natural Faculties, 1952,; also see Hippocrates, "On the Sacred Disease," translated by Francis Adams
15. Hippocrates, "Aphorism," section III, #22, translated by Robert Maynard Hutchins, " "Great Books of the Western World: Hippocratic Writings on the Natural Faculties, 1952, 
16. Hippocrates, "Aphorism," section III, #26, translated by Robert Maynard Hutchins, " "Great Books of the Western World: Hippocratic Writings on the Natural Faculties, 1952, 
17. Hippocrates, "Aphorism," section VI, #46, translated by Robert Maynard Hutchins, " "Great Books of the Western World: Hippocratic Writings on the Natural Faculties, 1952, 
18. Eadie, Mervyn J., Peter F. Bladin, A disease once sacred: a history of the medical understanding of epilepsy," 2001, England, John Libby & Company Ltd.
19. Hippocrates, "On the Sacred Disease," translated by Francis Adams

1501-76: Cardano finds new remedy for asthma?

Girolamo Cardano (1501-1576)

It was sort of by chance that our next subject enters our history of asthma.  His name was Gerolamo Cardano, and he's often given credit as the first to suspect asthma was a reaction to substances in the air around us, and the best remedy is avoidance of such substances.  

The story goes that he was born illegitimately in 1501 to a lawyer who taught him mathematics.  He was a brilliant child, and highly critical, so he was not well liked.  Realizing he had a mental advantage over others he became consumed by the gambling bug.  These vices would plague him his entire life.

Yet while a vice of his own making, his gambling worked to the advantage of everyone as this is what lead him to devising his rules of probability, which ultimately lead him to becoming one of the founders of that field.

In 1524 he used this newly obtained wisdom to write a book called "Liber de ludo aleae" which translates into "Book on games of chance."  Yet this book would not be published until 1663.

He earned his medical degree in 1525 and set up a small practice that didn't take off mainly due to his reputation.  So he returned to gambling, and it got so bad that he had to barter off his wife's jewelry and some furniture.  (1)

Cardano wrote over 130 books

Eventually he was able to get a job teaching math in Milan that afforded him free time to get his practice going.  After curing a few patients his reputation improved and he was admitted into the College of Physicians in 1539.   (2)

This was when his writing career took off.  He published books on mathematics, philosophy, astronomy, theology and mathematics.   He became famous for his ability to create and solve equations.  His most famous book was an algebra book published in 1545 called "Ars Magna." (3)  

He became professor of medicine at Pravia University and became rich and even more famous.  In his quest to study asthma, and develop his own remedies, he took up the task of reading Maimonides Treaties on Asthma.  It was about this time, in 1552, he was summoned by one of the richest and most famous men in the world to solve a stubborn case of the asthma.
###

John Hamilton was the Roman Catholic archbishop of St. Andrews and a member of a famous family in Scotland, and he was struck with a pretty bad case of asthma.  His doctor believed his asthma was caused because his brain was cold and this caused phlegm to build up in the chest, yet Hamilton's asthma did not get better by any of his "warming" therapies, such as making rooms hot and smoky. (4)

Cardano in 1553

Desperate for a remedy, Hamilton summoned Cardano who immediately accepted the invitation.  After examining Hamilton's habits for six weeks Cardano decided Hamilton's asthma was caused by too much heat and not too much cold.  His asthma, thus, was caused by a life of luxury and venery. (5))

Cardanos remedies were designed to cool the body:

1. A simple life
2. Cold water to the head followed by cold water showers
3. Inhalations of elaterium
4. Aplications of an ointment of tar, mustard, euphorbium (derived from herb sometimes called 'asthma weed', honey, of anthardus, and blister-fly to the skull
5. NO FEATHERS IN HIS PILLOW (silk, straw and seaweed instead)
6. No fires in the fireplace (6)

Hamilton's health almost immediately improved.  Cardano was paid heavily for his cure, not just in finances but by improved fame. He published his remedies in his book "Consilia," which is a report on individual cases and the treatments that worked.

Many writers have given him credit as the first to recognize allergens and to suspect that allergen avoidance will prevent asthma. 

Yet not so fast.  The truth is Cardano might simply have been lucky.  You see, he, like many physicians -- including Hamilton's former physician -- believed diseases were caused by an imbalance of the four humors.  

Yet not so fast.  Cardano didn't so much believe that fires and smoke caused asthma, and removing the asthmatic from such "asthma triggers" would cure the asthma.  He merely recommended these things because he believed they produced heat.  

Ars Magna

So while his remedies may have helped cure Hamilton, and probably many asthmatics in the days thereafter, it wasn't because he thought feathers and smoke were causing it.  He, in essence, was the benefactor of a little good fortune.

Yet Cardano's good fortune would end.  His daughter died of syphilis after years of selling herself as a prostitute, although her death spearheaded one of the earliest ever books on the condition.

His eldest of four sons was convicted of poisoning his wife and this son was beheaded in 1560.  Another son was a gambler.  Cardano was now the father of a killer, and he became a hated man.  He was relieved of his post as professor of medicine at Privia.  

To make matters worse he was convicted of heresy for casting the horoscope of Jesus, and spent time in jail for that.   He bequested the help of Hamilton to get him off the hook, and Hamilton was able to convince authorities to release the physician.  Yet Hamilton himself was soon therafter hanged.

Throughout his colorful life he wrote over 130 books.  And while he's remembered mainly for his accomplishments in algebra, the story of how he cured the archbishop of his asthma is one we asthmatics most cherish.

He later admitted himself he lost a lot of time and accomplishments by his gambling, which included chess and poker.  He passed away in 1576 with 100 books left unfinished. In his will dated 1566 his advice to his eldest son's boy Fazio was to avoid gambling.  

References:

1.  http://www2.stetson.edu/~efriedma/periodictable/html/Cd.html
2. ibid
3. ibid
4. Jackson, mark, "Asthma: The Biography," 2006, New York
5. ibid
6. ibid

1800-1900: The birth of the TB sanatorium

La Miseria by Cristóbal Rojas (1886) depicts TB late 19th century

By the mid 19th century it was well known that if you were diagnosed with tuberculosis, there was an 80 percent chance you were going to die.  So the outlook for those infested was bleak.

To make matters worse, tuberculosis was a serious threat to society at this time, making it a well known malady and a well known killer.  People had a very pessimistic view of it, and often became submissive to it thinking it was the will of God.

From about the mid 19th century to the turn of the 20th century it was the leading cause of death.  Most every family had either a family member or knew of someone who had the disease or had died from it.

By the end of the industrialized revolution, or by the end of the 19th century, over seven million people had been inflicted by the disease, and at least 50 percent of the populace in America and Europe had been directly impacted by it.  The hardest hit areas were highly populated areas like New York and London.  At the turn of the century it was estimated that over seven million people were dying from the diease yearly.  (12, page 14)

It was a common killer yet people knew so little about it.  They had no idea that overcrowding and poor sanitation was a significant reason for it's spread.  They had little knowledge that it was spread by droplets in the air breathed.  Humid and poorly ventilated rooms created great breeding grounds for Micobacterium Tuberculosis.

Carl von Rokitansky of Vienna (1804-1878) performed many autopsies on tuberculosis victims, and studied the tissue of organs of many who survived.  He learned that of those who survived up to 90 percent had "tuberculous lesions within the normal tissue of the lung."  (1)

Hermann Brehmer (1826-1889) was diagnosed with the condition while he was a botany student in the late 1840s, and he was told my his doctor that he might benefit from the clean air of the Himalayas.  So journeyed there to study plants, and by 1854 her returned to Germany with a new mission to study medicine and ultimately learn more about consumption.

He aimed to add on to the works of Rokitansky.  He described that not all people die from the disease, that many develop "healing of the tubercles in the form of scar formation, calcification, and adhesions, before disintegration and destruction of the lung tissue with its accompanying harmful effect on the whole organism had set in," according to Hugh M. Kinghorn in his paper aptly titled "Hermann Brehmer." (1) 

He wrote a paper "Tuberculosis is a curable disease," in which he was adamant that consumption was a curable disease.  He recommended those inflicted with the condition eat well, get plenty of rest, and exercise.  He was also the first to recommend isolation of those infected both so the victims could receive the proper treatment he recommended, but also to prevent contamination of healthy people.

While he would fight his entire life to convince the medical community that his ideas and treatment for consumption were on the right track, he was the only one to have any success in treating the Great White Plague in Europe during the 19th century.

Yet it took a little luck and some hard work to get his project going.  In 1849 the eldest sister of Brehmer's first wife, Marie V. Colomb, established a hydrotherapy institution in Gorbesdorf, which is a village in Silesia, Germany.  Yet her venture failed, and Brehmer took advantage of this and set up his sanatorium to prove he was right about tuberculosis.

Originally he ran into many problems.  He initially had only a few patients, one cow, and "and a lean horse to fetch coal from a distant place and patients from the station."  Yet after a few years he started to show success, and other physicians started sending him patients. 

Because he houses were private and he was having problems with the natives, he decided to build a "kurhaus" of forty rooms, an entertainment room and several kitchens.  This project was finished in 1862, and ultimately more rooms were added so it could house 60 patients. 

His project proved so successful that soon sanatoriums were being build in mountainous areas all over Europe and the United States.  One famous one in the United States was built in Denver, Colorado in 1899 by the Jewish Community. (Post on the opening of NJH to be published on 10/7/14) (See references 5 and 6 for more information on this)

In 1895 a German by the name of Wilhelm Konrad von Roentgen discovered the x-ray that allowed doctors to see the disease in its early as well as it's late stages.  This marked the first time that the disease could be diagnosed in its early stages instead of having to wait to see the late signs.  It also allowed doctors to see the tubercles in those who had survived the disease.  It showed both active and inactive tuberculosis.

The bacillus that causes consumption was first seen by Robert Koch under the keen eye of the microscope in 1882.  Koch attempted to find a cure and at one point thought he found it, yet he ended up being wrong and was ridiculed for his mistake.  He continued his work for a while, yet later gave it up to work in other areas.  (3) Yet he was so close, and may have succeeded if he just continued a little longer.

Yet another mistake made by Koch was that he joined forced with the German Government to market what he said was a cure.  Many TB patients rushed to Germany to receive his new treatment, and over two thousand TB patients received his remedy.  Yet many of these patients got worse, and faster.  Koch later admitted his remedy was only an extract of the tubercle bacilli. (7, page 17)

In 1907 Clemons von Pirquet proved a tiny scratch of tuberculin was enough to prove a sensitivity to it.  It was from this work, and the work of Koch, that in 1907 Charles Mantoux discovered the first technique to test for tuberculosis.  It became known as the Mantoux test, or the TB test.  It was modified in the 1930s so that it was able to be mass produced, and since then the test has been available.  Most people in the western world have had this little prick more than once.  (3)

However, by the end of the 19th century and the early 20th century sanatoriums for tuberculosis victims were popping up all over the place.

In 1900 tuberculosis was the leading killer in the United States, yet soon thereafter deaths from TB started to decline.  Success in battling TB is often attributed to improved living conditions, reduced crowding, improved sanitation, proper nutrition and isolation.  The sanatoriums probably helped in this regard, yet they also allowed those infected to get proper treatment. (4)

Cases of Tuberculosis have consistently declined in the United States and Europe so that the disease was actually believed to be extinguished in in western societies during the 1980s.  Yet recently some cases have been reported, and these were probably cases contracted while someone was traveling abroad to a third world nation.  TB continues to be a problem in many nations, particularly where sanitation and crowding continue to be a problem.

To make sure the disease remains rare in technologically advanced nations like the U.S., Europe and Australia, most people are tested yearly for the disease.  Most hospitals, mine included, make the test mandatory.

References: 

1. Kinghorn, Hugh M, "Hermann Brehmer," Trans Am Climatol Clin Assoc., 1921; 37: 193–210.
2. Warren, Peter, "The Evoluiton of the Sanitorium: The First Half-Century, 1854-1904
3. Shashidhara, A.N., K. Chaudhuri, "The Tuberculin Skin Test," The National Tuberculosis Institute, 1990, vol. 26, 1&2, March and June
4. Vynnycky, E., PEM Fine, "Interpreting the decline of tuberculosis: the role of secular trends in effective contact," International Journal of Epidemiology, 1999; 28; 327-334
5. Gurock, Jeffrey S., ed., "American Jewish History," 1998, New York, vol. 3, part 3, pages 1095-6
6. "The History of National Jewish," NationalJewish.org, http://www.nationaljewish.org/about/whynjh/history/
7. "The Captain of the Men of Death," Ulster Medical Journal, 1989, (Suppl): 7-9
8. Landau, Elaine, "Tuberculosis," 1995, New York, Chicago, London, Sydney, Franklin Watts, pages 13-32

5000 B.C.- 1750: TB spreads across the world

The 18-year-old Egyptian prince sat on the edge of the bed.  He was fiercely coughing, often bringing up blood which he spat on the ground.  The physician stood alongside him, gently touching the young man's shoulder, chanting an incantation.

He was concerned for his good friend who's skin was drawn taught over his ribs. He seemed to be slowly wasting away.  What the physician offered was the only known remedy for such a condition 2,400 years before the Birth of Christ. Yet his remedy didn't work, and the young prince was mummified.

The bacteria (mycobacterium tuberculosis) that causes tuberculosis (TB) has been around since the beginning of time, although it has evolved during that time too.  At first it may have been a harmless little bacteria, yet it evolved and started causing tuberculosis symptoms in animals.

Then, as humans started cultivating those animals about 8,000 to 5,000 years before Christ, they became exposed to Mycobacterium Bovis, the oldest known species of what is now Mycobacterium Tuberculosis. Evidence of TB was was found by paleopathologists (scientists who study ancient diseases) on human remains dating as far back as 8,000 B.C. (9)

A disease that sounds like tuberculosis was described in writing, etched in stone in cuneiform, by the Babylonian monarch Hammurabi.  He ruled from 1948-1905 B.C.

Some believe it's mentioned in the Bible, which was written in the 1000 year period before the conquests of Alexander the Great, in 327-6 B.C., as shachepeth in Leviticus 26:16 and Deuteronomy 28:22 may be pthisis, which is pulmonary tuberculosis. (11)

Some believe the Bible referenced the condition when Moses said (Leviticus 26: 16, Deuteronomy 28: 22):

Then I will do this to you: I will bring upon you sudden terror, wasting diseases and fever that will destroy your sight and drain away your life. You will plant seed in vain, because your enemies will eat it.

A similar reference was made by Moses in another Biblical book (Deuteronomy 28:22)

"The LORD will strike you with wasting disease, with fever and inflammation, with scorching heat and drought, with blight and mildew, which will plague you until you perish."

However, its difficult to accurately interpret the diseases described in the Bible as knowledge of diseases were scant, which made it difficult to describe them.  Mostly symptoms were listed, which requires the interpreter often to assume what disease is referred to.  Likewise, some symptoms in the Bible may be exaggerated for emphasis of what might happen if a person is evil. (11)

The victims of the bacteria didn't always show symptoms right away.  Sometimes they never did.  Yet the ones who did often developed a strong, harsh cough that was often productive of blood.  They often lost weight, had chills, night sweat and became extremely fatigued.  While some lived to tell about it, most didn't.

The malady was given a name when the Hippocratic (466-377 B.C.) writers referred to it as phthisis in 460 B.C.  Phthisis means wasting away. They described phymata, or tubercles in the tissue of humans and cattle, sheep and pigs. (9)  This is neat because phthisis and pneumonia are the only two lung diseases that were not categorized under the asthma umbrella.  

Hippocrates, the great Greek physician, was the first to write about it as a medical condition, although he acknowledged it had been around for a long time.  He wrote that it was "The greatest and most dangerous disease and one that proved fatal to the greatest number." (1, page 1)

Yet the Hippocratic writers considered it to be a hereditary as opposed to a contagious disease. Aristotle considered it to be contagious, which opposed general consensus at the time.  It was once described as "captain of all these men and death." (10) 

Isocrates is often considered as the greatest rhetoricians' in Ancient Greece.  His intent was to improve the speech and writings of individuals by instilling virtues.  He was born in 436 BC, seven  years before Plato was born.  Both Isocrates and Aristotle also mentioned that phthisis was contagious.  (1) 

Galen wrote about the malady too, and he believed it was an "ulceration of the lungs, thorax or throat, accompanied by a cough, fever, and consumption of the body by pus."  He considered the treatment for the malady to be living at high altitudes, like the top of a mountain.

From about 1066 to 1485, which are considered to be the Medieval or Middle ages in Europe, the condition was referred to as King's Evil "because newly crowned kings (and queens, in England) were alleged to cure scrofula, glandular swellings in the neck associated with TB, with their touch." (2)

Fracastonius of Verona (1478-1553) was the first to use phthisis exclusively for tuberculosis of the lungs.  Franciseus Sylvius (1614-1672) observed tubercles in the lungs of people with pthsisis and is credited with coining the term tubercle.  The tubercle described by the Hippocratic writers now had a name.

After 1492 Europeans started sailing for America.  In America the disease spread too, killing many.  Some believed it was a European disease and the Europeans brought it to America.  Yet evidence of Native American remains show that the disease had made its way to America long before the Europeans. (12, page 13)

So we have a disease that was not prejudiced who it invaded, as the disease was seen all over the world. Most people on the planet had either been inflicted with it, or had seen someone suffer from one or another forms of the disease.  Little was known about it, and there was no cure.  So, for the most part, people saw it as the will of God.  If you didn't catch it, you were lucky.  If you got it, you dealt with it.  If someone you knew got it, you pitied and doted on him.  

The mummy of a 4,412 year old mummy was discovered in a tomb in Egypt.  It was a young prince, perhaps around 18-years-of age.  The mummy was diagnosed by modern experts as having tuberculosis.  This proved the disease has been around for a long, long time.  

By the 17th century the disease was so rampant that that at least one in five death certificates in the city listed consumption as the cause of death.  Yet those statistics would seem small considering what the disease would do to mankind during the following two centuries. (12, page 13)

References:

1. Norris, Charles Camblos, "Gynecological and Obstetrical Tuberculosis," 1921, New York, London
2. Koehler, Christopher W., "Consumption, the great killer," http://pubs.acs.org/subscribe/archive/mdd/v05/i02/html/02timeline.html
3. "History of TB," New Jersey Medical School, Global Tuberculosis Institute, http://www.umdnj.edu/ntbc/tbhistory.htm
4. Klebs, Arnold Carl, "Tuberculosis," 1909, New York
5. Morton, Samuel, "Pulmonary Consumption," 1834, Philadelphia
6. Flenner, Simon, , "Immunity in Tuberculosis," Annual report of the Smithonian Institution, 1907, New York, page 627 
7. "Captain of the Men of Death," Ulster Med J. 1989; 58(Suppl): 7–9.
8. Sigeris, Henry E, "A History of Medicine," volume I, "Primitive and Archaic Medicine," Second Edition, 1955, New York, Oxford University Press, page 53
9. Seth, Vimlesh, SK Kabra, Rachna Seth, "Essentials of Tuberculosis,"  Third ed., Jaypee Brothers Medical Publishing, 2006, page 3-4
10. Jones, Greta, "Ca;ptain of All These Men of Death," 2001, New York
11. Prioreschi, Plinio, "A History of Medicine," 1991, volume I, "Primitive and Ancient Medicine," Edwin Mellen Press, Chapter VII, "biblical Medicine," page 514
12. Landau, Elaine, "Tuberculosis," 1995, New York, Chicago, London, Sydney, Franklin Watts, pages 13-32

Photos:

• 1.  from  http://www.grantvillegazette.com/articles/The_White_Plague

Further reading:

• essentials of tuberculosisi in children

980-1037: Avicenna: The Prince of Physicians

Avecinna (980-1037)

While the Western world slid into the dark ages between the 6th and 12th centuries, with most scientific and medical wisdom being lost, the opposite occurred in the Arabic world where Avecenna was born in Persia in  980 A.D.  He was a famous medieval philosopher and physician, and his book "The Canon" was one of the most well used medical texts for over five centuries.  
His official Arabic name was Abn Ali Al hosain Ibn Abdullah Ibn Sina, yet to the western world he's simply referred to as Avicenna. He was born in Afshena, one of the hamlets of the district of Bokhara in 980 A.D. His father was Abdullah, a local governor, and his mother was Sitareh.  (6)(8, page64)

His parents must have been pretty impressed by their young child, as explained by Fourgeaud said: (7, page 193-194)

His extraordinary memory, his extreme faculty for learning, soon attracted the attention of his father, who spared neither expense nor trouble for his education.  His power of memory were such, we are told by himself, that before he was ten years of age, he could repeat the whole of the Koran, and could converse familiarly on arithmetic, geometry and astronomy.  He repaired to Baghdad to study philosophy and medicine, and so entirely did he devote himself to these sciences, that he is said to have labored day and night, and to have warded off the approach of sleep and excited his exhausted faculties by the use of exhilarating beverages -- and when nature prevailed over all of his contrivances, problems that baffled his waking hours were solved in his dreams. (7, pages 193-194) (8, page 54)

According to his biography, he was so gifted as a student that his father assigned him a special instructor -- al Natali -- to teach him arithmetic, logic, science and astronomy.  In his early teens his interests shifted toward medicine, and when he was only 16 he became a physician. (6)

In fact, Fourgeaud said:

Before he was sixteen he not merely knew medical theory, but by gratuitous attendance on the sick had, according to his own account, discovered new methods of treatment.  By the end of his seventeenth year he had gone the round of learning of his time; his apprenticeship of study was concluded, and he went forth to find a market for his accomplishments." (8, page 64-65)

His quest did not take long, for he was only 16 when he became a "renowned physician."  Then, at the ripe age of 18, he earned fame and respect when the sultan of Bukhara, Nuh ibn Mansur al-Samai, became seriously ill and the person credited for healing him was Avecenna. As a reward for his services, Avecenna was granted access to the Sultan's library, which was loaded with all the wisdom of the ancient world. Avecenna loved to learn, so this was a great gift for him.   (6)(7, page 194)

He spent many hours studying by candlelight many volumes of books, most of which were those of Hippocrates and Galen, cramming his head with as much information as he could.  By the time he was 21 he had already started publishing volumes, sharing with others all he had learned.  In total he would write hundreds of volumes on a variety of topics, including ethics, logic, philosophy, science and medicine.  (6)

Bear with me now as I allow Fourgeaud and Bradford to tell the story of Avicenna, as I believe this is necessary in order to make a valid point.  When Avicenna was 22 his father died, and soon thereafter 'the reigning dynasty came to an end in the year 1004," said Thomas Bradford. He added:

Mahommed of Ghazni sought to attach the brilliant scholar to his retinue of learned followers, but he declined the honor, and made his way westward to the city of Urdjensh, in the modern district of Khiva, where the Vizier, who was a friend of scholars, gave him a small monthly stipend. But the pay was small, and Avicenna wandered from place to place through the districts of Nishapur and Mero to the borders of Khorasan, seeking an opportunity for his talents. Finally at Jorjan, near the Caspian, he met a friend who bought near his own house a dwelling in which Avicenna lectured on logic and astronomy. For this patron several treatises were written; and the commencement of his great Canon of Medicine dates from his stay in Hyrcania.(8, page 65)

He moved from place to place, writing all along, and "ultimately he," said Bradford:

Went southward to Hamadan, where the prince was established.  He first entered the services of a high born lady, but the Emir (sultan) learned of his arrival called him in as a medical attendant, and sent him back with presents in his dwelling.  He was now raised to the office of Vizier, but the turbulent soldiery mutined against their young sovereign, and demanded that his new vizier should be put to death.  Shems Addula consented that he should be banished from the country.  Avicenna remained hidden for forty days in a sheikh's house till a fresh attack of illness caused the Emir to again call for his physician.  Even during this troubled time he continued to study and teach. Every evening extracts from his great works, the Canon and the Senatio, were dictated and explained to his pupils; among whom, when the lesson was over, he spent the rest of the night in festive enjoyment with a band of singers and players.  (8, pages 65-66) 

He was likewise known as a good politician, yet despite the long-term popularity of his book "The Canon," he did not have much "'pull' with the authorities of his time." (2) 

This is evidenced through the words of Fourgeaud, who added that after he was appointed visier many vicissitudes beset his path. Fourgeaud wrote:

He was thrown into prison, where he remained two years, for being accessory to a conspiracy, or according to some historians, for refusing to administer poison to the nephew of a Sultan. For some time after his release he had to conceal himself, but being discovered he was once again incarcerated for four months, when he effected his escape under the disguise of a monk.  He then made his way to Ispahan, where he was treated with great distinction." ( 7, page 194)

Bradford continues telling the story:

On the death of the Emir, Avicenna ceased to be Vizier, and hid himself in the house of an apothecary, where, with intense assiduity, he continued the composition of his works. Meanwhile he had written to Abujaafar, the prefect of Ispahan, offering his services; but the new Emir of Hamadan, hearing of his correspondence, and discovering the place of his concealment, imprisoned him in a fortress. War continued between the rulers ofI spahan and Hamadan. In 1024 the former captured Hamadan and its towns, and expelled the Turks. Avicenna, after the war, returned with the Emir to Hamadan, and carried on his literary labors; but at length, accompanied by his brother, a favorite pupil, and two slaves, he made his escape fromt he city in the disguise of a Sufite ascetic. (8, page 66)

After a perilous journey they reached Ispahan, and received an honorable welcome from the prince. The remaining ten or twelve years of his life he spent in the service of his patron Abu Jaafar Ala Addaula, whom he had accompanied as physician and general literary and scientific adviser, even in his numerous campaigns. During these years he began to study literary matters and philosophy. But amidst all his study Avicenna never forgot his love of enjoyment. Unusual bodily vigor enabled him to combine severe devotion to work with indulgence in sensual pleasures. His passion for wine and women was almost as well known as his learning. (8, pages 66-67)

But his bouts of pleasure gradually weakened his constitution; a severe colic which seized him on the march of the army against Hamadan was checked by measures so violent that Avicenna could hardly stand. On a similar occasionthe 'disease returned; with difficulty he reached Hamadan, where, finding the disease gradually gaining ground, he refused to keep up the regimen imposed, and resigned himself to his fate. On his death-bed remorse seized him; he bestowed his goods on the poor, restored unjust gains, freed his slaves, and every third day till his death listened to the reading of the Koran. He died in June, 1037, in his 58th year, and was buried among the palm trees by the Kiblah of Hamadan. (8 page 67)

I transcribed for you here a synopsis of the life and times of Avicenna to show how difficult it was for a man of his stature during his time.  In order for him study medicine, practice medicine, and write about medicine he had to constantly gain the favor of the sultan. If he wasn't willing to make such a sacrifice, the wisdom of the ancient medical sages would probably be lost forever.

While he did come up with some ideas on his own, his writings mainly save for us the ideas of Hippocrates and Galen, but also the surgical wisdom of Paul of Aegineta, who was perhaps one of the greatest surgeons of the ancient world. Of course he also preserves for us many of the ideas of other ancient medical sages as well, such as Areteaus. (7, page 194) (8, page 68)

Instead, the Canon was translated into Latin in 1492 and would become the medical encyclopedia, or medical Bible, for Europe during the 15th, 16th and 17th centuries. (6, 1)  During these times, the Canon was used at the various universities throughout Europe to teach the wisdom of the medical sages, and it even eclipsed the writings of the other Arabic physicians of his era, including Rhazes, Haly Abbas, and Avenzoar.  (8, page 67) (7, page 194)

Mark Jackson, in his 1987 book "Asthma: The Biography," said the Canon was about: 

"According to Ibn Sina, asthma was a chronic disease in which patients often suffered 'acute paraxysms with similarity to the paroxysms of epilepsy and spasm.  The flow of thick humours from the head to the lungs produced a situation in which 'the patient finds no escape from rapid panting, like the labored panting of one who is being choked or rushed'.  (3, pages 30-31)

Jackson listed Avicenna's recommended treatment for asthma: (3, pages 30-31):

1. Purging
2. Vomiting
3. Blood letting
4. Voice exercises
5. Fats of hares
6. Deer
7. Gazelles
8. Penises of foxes
9. Lungs of foxes (3)
10. Arsenic in a pill with pine resin in a drink with honey water or inhalation (5, page 325)
11. Sulphur in water with soft boiled eggs or inhalation

In 1933 E. Stolkind described Avicenna as not providing much new information as was provided by Galen.  However, Avicenna, along with other physicians of his day, mentioned the relationship between asthma and nerves of the brain.   (4, pages 1121-2) Along with the brain, he also linked asthma with the liver and the stomach.  It's for this reason that he recommended arsenic as a remedy.  (5, page 408)

Some credit his demise to his excessive desire for wine.  (2, page 349)  He died of dysentery at the age of 58 in 1037.

Regarding "The Canon," Fourgeaud said thatJ:

The physicians of the middle ages accepted its teachings with the same faith with which they were accustomed to submit to the laws of the church... medical men were taught that Avicenna was "the Prince of Physicians" -- that he was infallible, that his works contained all the knowledge of the ancients and of the Arabians -- and they believed it; and were satisfied in following his precepts. (7, page 195)

His words were revered in much the same way as those of Galen were.  John Brock said that the Canon, "once translated into Latin, even overshadowed the authority Galen himself for some four centuries." (9, page xx)
  

References:

1. Drake, Miriam, "Encycopedia of Library and Information Science," 2nd ed., 2003, New york, page 1840
2. Michael, J. Edwin, ed., Medical and Chirurgical Faculty of the State of Maryland, "Maryland Medical Journal," May 1891-Oct. 1891, Baltimore, vol. XXV, page 349
3. Jackson, Mark, "On Asthma: The Biography," 2009, New York, pages 30-31
4. Stolkind, E, "The History of Bronchial Asthma and Allergy," Proceedings of the Royal society of Medicine, "1933, Vol 26, part 2, Great Britain, pages 1121-2
5. Aegineta, Paulus, translated by Adams, Francis, "The Medical Works of Paulus Aegineta, The Greek Physician, 1834, vo 1, page 408
6. "Avecenna: Prince of Physicians and Giant in Pharmacology," http://www.afghan-network.net/Culture/avicenna.html
7. Fourgeaud, V.J, "Medicine Among the Arabs," (Historical Sketches), Pacific medical and surgical journal, Vol. VII, ed. V.J. Fourgeaud and J.F. Morse, 1864, San Fransisco, Thompson & Company,  pages 193-203
8. Bradford, Thomas Lindsley, writer, Robert Ray Roth, editor, “Quiz questions on the history of medicine from the lectures of Thomas Lindley Bradford M.D.,” 1898, Philadelphia, Hohn Joseph McVey
9. Brock, John, "Galen on the natural faculties," 1916, London, New York, William Heinemann, G.P. Putnam's Sons

Further reading:

1. Check the above and this for aegeneta postssss

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