120-200 A.D.: Galen becomes world's greatest physician

Galen (About 120-200 AD)

Claudius Galen of Pergamum was a Greco-Roman physician who lived from about 130-200 AD, or about 500 years after Hippocrates. He was the first physician to search for and discover the answer to the question "What causes disease?"

He would ask questions like:

• What causes epilepsy?
• What causes fever?
• What causes pain?
• What causes dypsnea?
• What causes asthma?

He wasn't satisfied with the answer: the gods cause and cure diseases. Surely that was true, but he wanted to know specifics, like: 

• Why do bodies form?
• What causes life?
• What causes maintains good health?
• What changes occur to cause diseases?
• How are diseases cured?

As a student these questions formed in his mind, and as a student, and later as a physician, he sought for answers.  He inspected the human body every chance he got, although it was illegal to dissect the human body for learning purposes.  So he usually had to be content to dissect mice, apes, pigs, and other such animals. Later, as a surgeon at the gymnasium at Pergamum he was able to see the insides of wounded humans. Although most of what he learned was from other physicians and sages around the world.  

This is a depiction of what Galen may have seen as he approached Pergamum.

Galen was born in Pergamum (Pergamos, Pergamon), which was a city-state of Greece, according to historian Jeanne Bendick.  She said there were grand palaces, houses and temples to the gods.  There was a library second only to the library at Alexandria.  There was  gymnasium where young men learned to become athletes, and where they were educated.  It was also a place where baths were taken.  There was also a coliseum where gladiators fought and where plays were performed.  (9, page 14)

The school Galen attended was build near a temple the god of health and healing.  To Galen and other Greeks this god was referred to as Asclepius, but to the Romans he was called Aesculapius. He was the most powerful of the gods of health and healing.  Around his temple was a gymnasium, a school, a library, a large bath with cold and hot water, and together these were referred to as the museum.

View of Acropolis from Sanctuary of Asclepion as it would be seen today.

Bendick said that "about 250 years before Galen was born, the last ruler or Pergamum had given his city-state to Rome on the condition that Rome would protect its independence.  But the people who lived there still considered it a Greek city."  Today Pergamum is part of Turkey.  (9, page 2)

Most physicians when Galen was born were poorly trained, and many were simply quacks.  This was because there were no requirements to be a physician and anyone could claim to be one. (7, page 53) (9, pages 3-4)

Pretty much, if a person claiming to be a physician succeeded in curing people he gained the respect of his peers and was able to continue his practice.  If he failed to cure, he often times was forced to seek another profession.  (9, page 3-4)

Galen's father was Nicon, and like most who were educated during this era, Nicon was educated in most wisdom of the day, and he specialized in one or two areas.  Bendick said Nicon specialized in engineering and architecture, although he was also knowledgeable in philosophy, astronomy, and botany.  (9, page 9)

Medical historian Thomas Bradford said Nicon was a man of great wealth and influence in Greece.  Medical historian John Watson said that Galen's father made sure Galen received the best education in philosophy and medicine, of which Galen would specialize in.  (1, page 149)

Historian John Brock referred to a quote by Galen himself, where he describes his own parents.  Galen said  (10, page xv)

I had a great good fortune to have as a father a highly amiable, just, good, and benevolent man. My mother, on the other hand, possessed a very bad temper; she used sometimes to bite her serving-maids, and she was perpetually shouting at my father and quarreling with him -- worse than Xanthippe and Socrates. When, therefore, I compared the excellence of my father's disposition, with the disgraceful passions of my mother, I resolve to embrace and love the former qualities, and to avoid and hate the latter. (10, page xv)

Brock said Galen tried to collect in himself the best of his father, and to escape from his mother.  However, the fact that Galen continued to get into conflicts during the course of his life, and to openly toot his own horn and blast those who disagreed with him, may have been evidence he was never fully able to escape his mother's scorn.  (10, page xv)

Many Greek and Roman citizens did very little work.  This was because when lands were conquered, those who were taken prisoner were turned into slaves who did all the work.  The citizens, therefore, were able to enjoy the profits of the work of others.

Bendick said this was the case with Nicon and his son Galen.  He said:

They could spend as much time as they wanted reading, studying, discussing ideas, and amusing themselves.  Nicon probably got paid for designing buildings and engineering projects, but he never had to earn a living.  He and his friends never had to help around the house, or take the children to school, or even dress themselves if they didn't want to.  They had slaves to do all the work." (9, page 9)

Bendick said that most children were educated by their mother until they were eight, but Galen's father took special interest in educating his son.  What Galen didn't learn from his father he learned from his father's slaves. Since young citizens were not allowed to go to the public library, this didn't matter to Galen, who had access to his father's private library, which had over a thousand scrolls.  (9, pages 9, 17-18)

Nicon could easily afford to send his son to the best universities.  Watson said that by the time Galen was seventeen:

"He was placed as a student at the Asclepion of Pergamum, under Satyrius, the pupil and successor of Quintus; and in the course of his studies had the advantage of instruction from Stratonicus, a Hippocratic rationalist, and from AEschrion, an emperic."  (1, page 149)

Medical historian Thomas Bradford said that the students of this era had very rare access to books, which was why it was important to learn at the Asclepions.  Everyone educated was instructed in all the wisdom of the day, which is why pretty much all ancient philosophers were also considered physicians.  Galen, however, paid special attention to medicine and surgery, and practiced it.  He thus became one of the most prolific physicians of his time and of all time.  (7, page 54)

It was at the ripe age of 14 that he commenced his studies of philosophy, and when he was seventeen he started his study of medicine, which took him three years to complete.  (7, page 53)

After graduating from school it was important for those desiring to become exemplary in their skills to travel to in order to learn from those most proficient in their skills.  This would explain why Galen, at the age of 21, " went to Smyrna, thence to Corinth, then to Alexandria and to other cities" before opening his own medical practice at Pergamum at the age of 28.  (7, page 40, 53)

Watson said that Alexandria was, at this time, "still most celebrated school of medicine." (1, page 149) Historian Edward Meryon said that studying in Greece, Asia and Italy was common practice for aspiring physicians, "justly regarding such a course as essential to an accomplished physician." (2, page 77)  

When he was 28 he returned to Pergamum and started his own medical practice. (7, page 40, 53) Perhaps in order to broaden his skills, he also signed a three year contract to be a physician to the gladiators.  He trained the gladiators, and then he treated their cuts, scrapes, broken bones, and other wounds. (9, pages 62-70)

In doing this he became very proficient at the basic surgical wisdom of ancient physicians.  There were wounds that occurred during the practices that occurred daily, but there were severe wounds, and some deadly wounds, that occurred during the actual fights.  He would have seen some cuts so deep he would have seen the lungs, and the beating heart.  (9, pages 62-70)

This was significant because of his inability to dissect humans.  Perhaps this inspired him to learn more, and to come up with theories.

Of these years of Galen's life, Bradford said: 

Here he was held in such high esteem by the people that the priests of Esculapius, through the Sovereign Pontiff or High Priest of the city, placed him in charge of the gymnasium then attached to the temple, at which the athletes and gladiators were daily in the habit of assembling to exercise. This office he held for several years, and it is said that he acquired great reputation for his skill in the treatment of fractures, and the wounds incident to the fierce combats of the time. Owing to a revolt in Pergamos, which occured in the year 163-4, and when he was 34 years of age, he was induced to leave that city and settle in Rome. His great renown had preceded him, and his great erudition and practical knowledge soon placed him in the first rank of his profession. (7, page 40-41)

Bradford said he was 34 when he decided to leave Rome. Bendick said he was 31.  This is a common confusion when trying to compile the life of such an ancient person as Galen.  Regardless, after three years as physician to the gladiators, Bendick said Galen decided to continue his studies, and open up a practice, in the greatest city in all the world: Rome.  The journey from Pergamum to Rome probably took him a year no matter what method he used to travel.  (9, pages 70-73)

Prior to his time in Rome he was not a famous physician.  As was typical of the ancient world, in order to gain fame you had to earn the favor of someone famous.  Bendick explains how Galen did this in Rome:

His fame began with his father's friend, Eudemus, who was getting sicker and sicker, even though his doctor was one of the most important in Rome.  Eudemus sent for Galen, who examined him carefully, made his own diagnosis, and prescribed treatment and medicine, which he made himself.  Eudemus recovered and suddenly important people all over rome wanted Galen to be their doctor.  

The important people were not only those who were rich, or who were government officials.  Orators and architects, philosophers and lawyers, astrologers and famous athletes were equals in Rome.  

One of the important people was the ocnsul, Flavius Boethius, wose wife was ill.  when Galen cured her, Boethius became his greatest fan.  He paid Galen a fee of 400 gold pieces for the cures.  (9, page 78-79)

Bendick said it was Boethius who encouraged Galen to give lectures to explain his medical ideas and his methods of curing sickness.   Now he would spend time at the gymnasium not as the student, and not as the physician, but as the lecturer of medicine.  (9, page 79)

While his father encouraged him to be well learned, from his mother he appears to have obtained a "violent temper."  He was a very "boastful" speaker, and by his lectures he "attracted not only students of medicine, but also philosophers, politicians, and many others of the highest rank and influence," wrote Bradford. (7, page 41)(also see 9, page 9)

Perhaps we can see his "boastful" speaking by his "boastful" writing.  In his Natural Faculties, he blatantly criticizes Asclepiades, a vast critic of Hippocratic medicine. Galen said that Asclepiades had opposing views as to Galen when it came to yellow bile and jaundice, and black bile and the spleen.  Galen also quoted Asclepiades as saying that "nothing is naturally in sympathy with anything else, all substance being divided and broken up into harmonious elements 'molecules.'"(11, page 62-63)

Of this Galen took exception, and wrote: (11, page 63)

He (Asclepiades) is forced here, again, to talk nonsense, just as he did in regard to the urine. He also talks no less nonsense about the black bile and the spleen, not understanding what was said by Hippocrates; and he attempts in stupid -- I might say insane -- language, to contradict what he knows nothing about. (11, page 63)

So, according to Galen, while Asclepiades did a service by introducing Greek medicine to Rome, he was wrong to contradict Hippocrates.  Regardless, by the time Galen began his studies of medicine in Rome, medicine was in a state of flux.

Historian John Brock confirms for us that the medical community was in a state of flux, or "ebb," at the time Galen started his practice.  Brock said: (10, page xvii)

Medical practice at this time was at a low ebb, and Galen took no pains to conceal his contempt for the ignorance, charlatanism, and venality of his fellow-practitioners.  Eventually, in spite of his social popularity, he raised up such odium against himself in medical circles, that he was forced to flee the city. Thus he did hurriedly and secretly in the year 168 A.D., when thirty six years of age. He betook himself to his old home in Pergamos, where he settled down once more to a literary life. (10, page xvii)

Bradford likewise confirms that that after five years in Rome, and angering many of his fellow physicians, he moved to Brindusium, and then "set out to visit the East; he visited different parts of Palestine and the isle of Cyprus."  (7, page 41)

He ended up, as Brockk said, in Pergamus where he had a brief respite, although it was short lived.  Brock said after a year he was summoned by Roman Emperor marcus Aurelius to return to Rome.  (10, page xvii)

Bendick said the year was 168 A.D. when Galen was summoned out of his respite to return to Rome, so once again you can see the confusion when it came to exact dates.  It is possible it was the same year that he left Rome and returned, although considering it took about a year to travel the distance between the two cities, this is probably not the case.

So it was about 168 A.D., give or take a year, that Marcus Aurelius championed his friends to the cause of winning the war.  He wanted Galen to be his own personal physician.  There were other amature physicians called medici who took care of wounded soldiers.  Galen's job would be to tend only to the physician, and when he returned to Rome that is exactly what he did. Although he really wasn't in Rome, he was wherever the Roman military was.  (9, pages 102-107)

Regardless, Bradford said he was appointed by Marcus Aurelius and Lucius Verus as surgeon general of the army, Galen followed the emperor for a time, (7, page 41) but he was not concerned about the charm, glory, and patriotism of being on the front lines with the emperor.  He surely wanted to stay in the good graces of the emperor and his country, but he wanted out of his duty of following the emperor in battle.  (10, page xviii)

There may have been a variety of reasons for Galen's feelings about the Roman military, although Bendick speculates it may have been because of his fear of plagues.  Bendick said that plagues (of all sorts) were common back in Galen's time, and it was very common for soldiers to come into contact with these plagues.  Historians say that a plague wiped out about a third the population of the empire during Galen's lifetime, and some speculate based on descriptions of the disease that it was smallpox.  (9, pages 102-107)(10, page xvii)

So Galen was afraid of getting the plague, and therefore he wasn't happy with his role in the military.  He therefore managed to convince the emperor that his services would be better fit back in Rome, and thus obtained his honorable discharge.  (9, pages 102-107)(10, page xvii)

Marcus Aurelius gave him his honorable discharge in exchange for being in charge of his nine-yearold son Aurelius Commodius. Galen then succeeded in curing the prince of a fever, and also curing his brother, Sextus. Of this, Bradford said: (7, page 41)

"(Galen) secured the favor of the boy's mother Faustina.  When the emperor came back he became ill, and the physicians said that he had ague; but Galen diagnosed dyspepsia and cured him. This greatly added to his fame, and the grateful emperor exclaimed: 'We have but one physician -- Galen is the only man in the faculty.'  Thus enjoying royal confidence, he devoted his time to practice, and to writing his immortal works on medicine, He passed the rest of his professional life in Rome."  (7, page 41)

So you can see that he had a pretty well established reputation among the aristocracy which, again, was something that was almost essential during this era in order to obtain a reputation among society.  He was also a great teacher, and gave lectures in the open.  Students yearning to learn might have traveled long distances to learn from the great physician.

Brock said Galen spent the rest of his days in Rome, and it was during this time that he did most of his writings.  There are various dates surrounding the date of his death.  Some say he died in 201 A.D., some say 202, some 210.  Some Arabic physicians noted his date as 215 or 216 A.D.  Brock perhaps said it best when he wrote, "Probably he died about the end of the century." (10, page xviii)

Galen died around the year 201 or 202 or 210.  Some say he died around 216.  So it's difficult to know for sure when he died.  Chances are, since all those numbers are similar, and since they were probably transcribed so many times, they were probably mixed up, and thereby making it impossible for modern historians to know when he actually died.

Through the course of his life he studied the works of the sages and physicians of the world, he studied all the books he could, and he performed experiments on his own.  He would find all the answers to his questions, write down his theories for other physicians to learn from, and he would go on to become the most famous physician not just of his lifetime, but of all time.

Further reading:

1. Galen: the worlds first pathologist
2. Galen wonders what causes asthma

References:

1. Watson, John, "The Medical Profession from the Earliest Times: an anniversary discourse delivered before the New York Academy of Medicine November 7, 1855," 1856, New York, Baker & Godwini
2. Meryon, Edward, "The History of Medicine," Volume I, 1861, London,
3. Fourgeaud, V.J., "Historical Sketches: Galen," Pacific Medical and Surgical Journal," 1864, Vol VII, San Francisco, J. Thompson & Co., pages 22-29
4. Jackson, Mark, "Asthma: A Biography," 2009, Oxford University Press, the quote from Jackson comes from On the Affected Parts by Galen
5. Young, Thomas, "A Historical and Practical Treaties on Consumptive Diseases:  Deduced From Original Observations, And Collected From Authors Of All Ages," 1815, London, B.R., page 145
6. Adams, Francis, "The Medical Works of Paulus Agineta: The Greek Physician; translated into English with a Copious Commentary," vol. I, London, page 407-8, 1834, Adams gives a long list of ancient physicians who wrote about asthma
7. 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
8. Garrison, Fielding Hudson, "Introduction to the history of medicine, 3rd edition, 1922, Philadelphia and London, W.B. Saunders Company
9. Bendick, Jeanne, "Galen and the gateway to medicine," 2002, U.S., Bethlehem Books Ignatius Press
10. Brock, Arthur John, translator and author of introduction, Galen, author, "Galen on the natural faculties," 1916, London, New York, William Heinemann, G.P. Putnam's Sons
11. Galen, author, Arthur John Brock, translator, "Galen on the natural faculties," 1916, London, New York, William Heinemann, G.P. Putnam's Sons
12. Gill, M. H., "Review and Bibliographic Notices: "On the spasmotic asthma of adults," by Bergson, published Gill's book, "The Dublin Quarterly Journal of Medical Science," volume X, August and November, 1850, Dublin, Hodges and Smith, pages 373-388
13. Freudenthal, Wolff, "Bronchial Asthma," New York Medical Journal: A Weekly Review of Medicine, edited by Edward Swift Dunster, James Bradbridge Hunter, Frank Pierce Foster, Charles Euchariste de Medicis Sajous, Gregory Stragnell, Henry J. Klaunberg, Félix Martí-Ibáñez, volume CV, January-June, 1917 (Saturday, January 6, 1917), New York, A.R. Elliot Publishing, Co., pages 1-5

Originally published 7/25/2012 and edited and resubmitted on 8/2/2012 and again on 10/29/2013 by Rick Frea

100 A.D.: Aretaeus defines asthma

Somewhere around 100 A.D., during the reign of Emperor Nero, lived an ancient Greek master clinician named Areteus of Cappadocia.  He was responsible for our first clear medical descriptions of diseases such as pleurisy, diptheria, tetanus, pneumonia, diabetes, epilepsy and asthma. He was the first person to recognize asthma as a disease entity of its own, and the only physician among the ancients to do so. (1)(6, page 1)

When he was born, died, and any details of his life are educated guesses.  Some think he practiced medicine somewhere in one of the Eastern Roman provinces,  and was educated in the same manner as Hippocrates: by physicians of Egypt. Only Aretaeus learned at the school of Alexandria in Egypt.  Alexandria at the time was the major center of medical wisdom mainly because it was legal to dissect the human body in Egypt and not in Rome and Greece.  (2, page 110).

All we know of him is what he left in print, which apparently was pretty impressive. John Watson, in his 1856 book, "The medical profession  in ancient times," gives this account of the works of Aretaeus (3, page 145): 

"Aretaeus is one of the most original and elegant writers of antiquity.  For truth and accuracy of description, some have even placed him above Hippocrates.  There is perhaps no modern writer to whom he can be aptly compared than Heberden.  He appears to have written at that period of life when the mind, tempered and enriched by ample experience, is more disposed to rely upon personal observation than on teaching of the schools, and to pay little regard to theories unsupported by the revelations of nature."

Like other Bryzantine physicians after the fall of Rome, he copied the works of the greatest physicians who came before him, particularly Galen, Aetius and Oribasius.  Although, despite his humility, he differs with them from time to time, adding in his own personal observations from his own experience. (4, page 71)

His objective is stated at the beginning of his De Re Medica:

I have composed this work in order to give a compendious course of instruction, and not because there is any deficiency in the works of the old masters in the art, for, on the contrary, everything is handled by them properly and without any omission, whereas the moderns have not only neglected to study them, but have also blamed them for prolixity... I have compiled this brief selection from the works of the ancients, and have set down little of my own, except a few things which I have seen and tried." (4, page 71)

In the time since Hippocrates there were few advances in medical thinking, so Aerateus revived Hippocratic ideas (2, page 110).

Like Hippocrates he believed health and disease were determined by a balance, or imbalance, of the four humors: blood, phlegm, yellow bile and black bile.  He was also a pneumacist (see pneumatism), meaning he believed diseases were caused by imbalances in the gases of the body.

Areteaus described an asthma attack this way:  (1, page 26)

"They breathe standing as if desiring to draw in all the air which they possibly can inhale; and in their want of air they also open the mouth as if thus to enjoy the more of it; pale of countenance except the cheeks which are ruddy; sweat about the forehead and clavicles; cough incessant and laborious; expectoration small, thin, cold, resembling the efflorescence of foam; neck swells with the inflation of the breath (pneuma); the precordia retracted; pulse small, dense, compressed; legs slender; and if these symptoms increase, they sometimes produce suffocation after the form of epilepsy.

But if it takes a favorable turn, cough more protracted and rarer; a more copious expectoration of more fluid matters; discharges from the bowels plentiful and watery; secretion of urine copious, although unattended with sediment; voice louder; sleep sufficient; relaxation of the precordia; sometimes a pain comes into the back during the remission; panting rare, soft, hoarse. Thus they escape a fatal termination. But during the remissions, although they may walk about erect, they bear traces of the affection.

Wolff Freudenthal, in a 1917 article in New York Medical Journal titled "Bronchial Asthma," said the following regarding Areteaus:

According to Areteus its seat is in the lungs, but he also knew that the auxiliary muscles of respiration are called into action as well as the diaphragm. The cause of the disease is a cold or a great deal of humidity in the air, factors which even nowadays are made responsible for many an ailment——mostly, of course, without any scientific basis. Aretaeus describes two forms of asthma: First, one in which there is a difficulty of breathing, as in running, climbing, wrestling, and every kind of hard labor. In order to breathe easier the nose becomes pointed. The description of an attack is very accurate. (6, page 1)

Second, a form called by him “pneumodes or dyspnodes." The differential diagnosis between the two varieties consists in the duration (the latter being more prolonged), in the age of the patient, the free intervals, etc. The chest is round, barrel shaped, but otherwise normal... (6, page 1)

A third form of asthma is mentioned by Aretzeus but not recognized as such, i. e., “orthopnoe.” It seems to us that he mentions this form only to place himself in opposition to Celsus, who, as is well known, had made three divisions, viz., dyspnoe, asthma, and orthopnoe. (6, page 1)

If you were a patient of his he had a new method of assessing you, and you can read about that in an upcoming post as noted below.

Further reading:

• Dogmatic School of Medicine (2/26/13)
• 50 A.D.: Pneumatic School of Medicine (5/1/14)
• 100 A.D. Areteaus assesses the asthmatic (5/6/14)

References:

1. Aretaeus of Cappadocia," Encyclopedia Britannica, http://www.britannica.com/EBchecked/topic/33531/Aretaeus-Of-Cappadocia, viewed on July 26, 2012
2. Magill, Frank N., editor, "Dictionary of World Biography," Volume I: The Ancient World, 1998, Salem Press Inc., California
3. Watson, John, "The Medical Profession in Ancient times.  An Anniversary Discourse Delivered before the New York Academy of Medicine, November 7, 1855," 1856, New York, Baker an Godwin, Aretaeus of Cappadocia, page 145
4. Fourgeaud, V.J, "Historical Sketches:  XL  Medicine from the time of Galen to the Arabic Period," Medical and Surgical Journal, edited by V.J. Fouregaud and J.F. Morse, Volume VII, 1964, San Franciscohed June 9, 2011, pages 60-72
5. Brown, Orville Harry, "Asthma, presenting an exposition of nonpassive expiration theory," 1917, St. Louis, C.V. Mosby Company
6. Freudenthal, Wolff, "Bronchial Asthma," New York Medical Journal: A Weekly Review of Medicine, edited by Edward Swift Dunster, James Bradbridge Hunter, Frank Pierce Foster, Charles Euchariste de Medicis Sajous, Gregory Stragnell, Henry J. Klaunberg, Félix Martí-Ibáñez, volume CV, January-June, 1917 (Saturday, January 6, 1917), New York, A.R. Elliot Publishing, Co., pages 1-5

2697 B.C.: The oldest description of asthma (sort of)

The oldest recorded medical document is the Nei Ching Su Wen (Classics on Internal Medicine) which was written about 2697 B.C. by the Yellow Emperor Huang Ti or, according to some sources, by sometime around 1000 B.C. and attributed to Huang Ti to give the document more value.  The document mainly consists of dialogue between Huang Ti and his physician Ch'i Pai.  Whether Ti truly existed or was a work of legend is still debated to this day by historians. 

While diseases weren't mentioned in the Nei Ching, there were definitely several references to breathing disorders.  One such example can be found in chapter 34, or final chapter of the document.  The discussion between Ti and Pai went like this:

The Yellow Emperor said:  " Man is afflicted when he cannot rest and when his breathing has a sound (is noisy) -- or when he cannot rest and his breathing is without any sound.  He may rise and rest (his habits of life may be) as of old and his breathing is noisy; he may have his rest and his exercise and his breathing is troubled (wheezing, panting); or he may not get any rest and be unable to walk about and his breathing is troubled.  There are those who do not get a rest and those who rest and yet have troubled breathing.  is all this caused by the viscera?  I desire to hear about their causes."

Ch'i Po answered:  "Those who do not rest and whose breathing is noisy have disorders in the region of Yang Ming (the 'sunlight').  The Yang of the foot in descending causes the present disturbance and is ascending it causes the breathing to be noisy.  The pulse of the stomach is located in the region of the 'sunlight'.  The stomach is the ocean of the five viscera.  If the breath (of the stomach) does not function there is a disorder in (the region of) the 'sunlight' and it cannot follow its course; the consequence is inability to rest.  In ancient classics it is said: 'If there is no harmony within the stomach, there is no peace (contentment, comfort, ease.

"Hence if the habits of life are as usual and the breathing is noisy, then the veins of the lungs are in disorder.  The vessels are not in harmony with the main vessels which ascend and descend.  Hence the main vessels are restrained and cannot function, and the man suffers from a disease of the veins.

"If, however, the habits of life are as usual and breathing is noisy; and if one cannot rest, or if one rests there is troubled breathing, then something has temporary residence in the breath; water follows the saliva and moves.  The water of the kidneys influences the saliva, disturbs the rest, and causes the troubled breathing."

The Emperor said:  "Excellent!"

Now if that's not a line a B.S. I don't know what is, but hence was the theory of medicine in Ancient China, and it was based on this that breathing disorders, like asthma, were diagnosed and treated.  To the health experts living at the time this explanation was completely rational. 

For more on the Nei Ching and asthma in Ancient China, click here. 

Reference:

1. Veith, Ilza, "The Yellow Emperor's Classic of Internal Medicine," Los Angeles, 2002, page 252-3 (Veith wrote the introduction and translated for us the Nei Ching as written by Huang Ti, the Yellow Emperor.)

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