1700-1970: Evolution of intubation

How procedure was performed circa 1891 (23, page 20)

Curious physicians started investigating the human body during the course of the 18th century, and they learned a ton about human anatomy.  Near the end of the century physicians used this improved wisdom to discover and invent better methods of saving lives, such as intubation and bag mask ventilation.  

Such inventions were crude back then, and the methods of performing them must have been traumatic for the patients receiving them, yet they gave physicians something to work with in order to help their patients.  The more these physicians struggled, the better they got.  The more they tinkered, the better their equipment got.

Here is a pithy progression of some of the results that transpired due to the hard work, and crafty thinking, of a few admirable physicians.

1500:  A paralytic discovered for modern world:   Curare (Succicholine) was one of the most famous native American poison, as the Indians often placed it on the tips of their arrows in order to paralyze their prey.   (18, page 4, 177-178)  Sir Walter Raleigh first reported the paralytic when he discovered that the South American Tupi Indians used the poison on the tips of their hunting darts.  (19, page 1674)

1773:  First resuscitation of near drowning victim:  According to a 1920 publication by the Lungmotor Company, "Drowning: Historical-Statistical Methods of Resuscitation," "The first reliable history of a resuscitation from drowning was that performed by M. Reamer in Switzerland. This was reported to the French Academy of Sciences and translated into English by Dr. Crogan in 1773. About this time Dr. Fothergill published his "Physical Dissertation on Drowning," which was read before the Royal Society in England. In 1773, the first society for the rescue of those apparently drowned was instituted at Amsterdam, Holland."  (20, page 3) (22, page 1)

1774:  Humane Society uses bellows to help drowning victims: Members of the society recommended the use of bellows to breathe for victims of accidents (mainly drownings).  They recommended that the end of the bellows be placed in one nostril, while the other nostril and mouth were occluded by a second operator. One problem that often occurred was air entering the stomach.  A second problem was the tongue blocking the airway. Goodwin ultimately recommended a catheter be inserted into the other nostril into the esophagus to prevent air from getting into the stomach and to keep the tongue from blocking the airway.  (22, page 2) (18, page 50-52)

1780:  Bag Mask Ventilation:  In this year a reservoir bag was attached to a mask and used to give breaths to infants who were not breathing at birth.  The device was invented by Chaussier.  He also invented a cannula (or catheter) that could be inserted into the airway by blind insertion through the mouth into the larynx.  His reservoir bag could then be inserted to the cannula to provide positive pressure breaths.  (1)  He was likewise the first to provide oxygen breaths to newborns.  (2)

1788:  Endotracheal tube:  The first endotracheal tube was invented in 1788 by Charles Kite (Kyte).  He was a surgeon who wrote an essay titled, "The Recovery of the Apparently Dead," in which he described inserting a tube he referred to as a catheter through one of the nares or the mouth to the lungs whereby the operator could either provide positive pressure breaths either by placing his mouth over a mouthpiece or by using bellows.  To cause expiration Kite recommended pushing in on the abdomen.  Various bellow-type systems were available for providing positive pressure breaths. He also recommended a catheter that was inserted into the esophagus to prevent the tongue from blocking the airway.  On the catheter as a ivory sliding piece that was slid down with a finger into the gullet in order to block the esophagus and prevent air from entering the stomach. Kite's equipment was included in the Case of Resuscitating Instruments that was kept at the various Receiving Houses (Rescue Stations)(1)(23, page 50-52)

1826:  Bellows fall out of favor:  Experiments in 1826 Leroy d'Etiolles performed studies using bellows and noted in a report that "bellows could kill an animal by suddenly inflating the lungs." (23, page 2) This was among the first reports that showed that over inflating the lungs with too much positive pressure could cause the lungs to collapse.  Due to this report, bellows were no longer recommended by the Humane Society.  (23, page 2) However, in 1888, "experiments by Leroy were performed that proved that a collapsed lung only occurred when the pressure forced into the lungs was too high, such as greater than 20-80 mm of mercury in the lungs of infants.  As a result of his experiments, he "invented a safety bellows to obviate these effects.  The bellows had a scale graduated in ages attached to the handles to limit the volume of air delivered." (1)  Experimenters in the succeeding years attempted to create a system of bellows, or methods o fusing them, that were safer to the patient.  

1793:  Intubation to treat diseased patients:  Prior to this time artificial respiration was generally used to treat near drowning patients or for some other purpose.  Yet near the end of the 18th century artificial respiration was thought to benefit people with diseases or conditions that result in dyspnea or asphyxia.  This was a time when a tube was sought to be kept inside the airway long-term as opposed to temporary.  Xavier Bichat, a pupil of French surgeon Desault, describes how Desault decided to insert a catheter into the larynx of a patient in impending respiratory failure as opposed to a tracheotomy. Desault is considered the first to apply artificial respiration for dyspnea.  In many cases the patient's breathing became easier, and in one case the patient's breathing became easier and was extubated 24 hours later. Desaults cather "was a large gum-sized elastic catheter, with two large eyes and an opening inferiorly, adn he introduced it through one of the nasal fossa rather than the mouth."  Catheterization became a common procedure in France, although later fell into disuse.  (3, page 2-4)

1800?:  A paralytic discovered for modern world:   Curare was one of the most famous native American poison, as the Indians often placed it on the tips of their arrows in order to paralyze their prey.  American physicians discovered this poison early on in the 19th century (exact date unknown).  Physicians tried to find a safe dose for using it as a paralytic, which was hard to do.  They also experimented with various diseases to see if it had beneficial effects.  The poison would become an important medicine used by physicians, although it would be a few years before it was proved useful as an anesthetic. (18, page 4, 177-178)

1807:  Method of making Curare discovered:  After Curare was mentioned by Sir Walter Raleigh, many people believed it was made from "poison dart frogs."  Alexander von Humboldt discovered that this was not true, that the poison was derived from various vines in the rain forest.  The stems, roots and leaves were crushed and boiled into a paste, which was sometimes mixed with frog and snake venom.  A thick black paste was placed on the tips of darts.  As they pierced through the skin, the poison would enter the blood stream causing the animal to become paralyzed.  Breathing would cease, and the animal was turned into easy prey.  This would be a major breakthrough for modern medicine, because it would allow physicians an opportunity to experiment with it on animals, and ultimately on patients of various types. (19, page 1674)

1814:  First use of experiments with muscle relaxants:  Benjamin Brodie (1783-1862) and was an English surgeon who performed experiments using Curare (Succicholine) on a donkey, and he proved that so long as the animal was provided with artificial breaths, it could be kept alive during an operation.   (2, page 227)(17, page 25) Charles Waterton gave the Curare while "Brodie supplied the experimental idea." Bellows were used to breathe for the animal for two hours.  The animal lived another 25 years. (17, page 25) 

1839:  Intubation fails  Dieffenbach of Berlin tried to catheterize the larynx of a patient inflicted with croup caused by diphtheria and failed. (8)

Figure 1(23, page 6)

1837:  Artificial breathing condemned:  In 1837 Leroy d'Etoille was concerned about the use of such artificial breathing because he suspected it caused emphysema and would collapse the lungs (pneumothorax). This simply provided another excuse not to perform the procedure, because after the germ theory was established in the late 19th century all methods of performing artificial breaths (positive pressure breathing) was banned for the next 100 years before it's value would be re-established in the later half of the 19th century.  (7)

1845:  Oxygen breaths: A man named Erichson invented the first device that provided positive pressure breaths with oxygen through a cannula inserted through a pipe inserted into one of the nostrils.  He recommended ten breaths a minute.

1850:  Jaw-Thrust technique recommended:  One of the problems that must have ensued when a patient was anaesthetised during surgery was asphyxia (or increased risk of it) due to upper airway obstruction.  To resolve this problem, anaesthesiologist Joseph Clover (1825-1882) performed the "jaw thrust- chin life" procedure."  The physician used chloroform as an anesthetic in over 7,000 operations without a single fatality, so other physicians must have been eager to copy his successful techniques.  Due to side effects, and the death of a little girl as a result, the use of chloroform started to wane by 1864, and by WWI was essentially replaced with better, safer anaesthetics (which included both explosive gases and injection through the hypodermic needle that was invented in 1855 by Alexander wood.) (10, page xxi)(9, page 7)

1855: Intubation fails:  Pediatricians become concerned about the large number of children with diphtheria who die despite emergency tracheotomies.  Reybard in Lyon tried to catheterize the larynx of a patient inflicted with croup caused by diphtheria, and failed.  Weinlechner in Vienna tried to catheterize the laryx of a similar patient, and he too failed.  (8)

(26, page 13)

1858:  Bouchut's Intubation Tube is rejected:  In this year French pediatrician Bouchut became the first to describe insertion of a tube into the airway as opposed to a catheter in a case of dyspnea. The tube he used was a rounded silver tube narrower at the end to be inserted as you can see in Figure 1 (see both figure ones).  It was 1.5 to 2 cm long and 7 cm in diameter. Interestingly, a silk thread was attached to the distal end of the tube that was "brought out to the mouth, and was intended to prevent the tube from going down the trachea or esophagus; and to allow it to be taken out when necessary." He later "insisted on the distinction between his method and catheterism." However, of the seven cases he cited to the French Academy of medicine, only two lived and both required tracheotomy.  

Yet he proved the procedure could be done. Various other physicians described success with this or similar procedures between 1858 and 1880 when the Joseph O'Dwyer introduced his tube.(3, page 5) Some speculate the reason Bouchut's intubation tube (tubage de la glotte), which "set in the glottic space for a few days" was doomed to be rejected due to a bias created by Dr. Armand Trousseau, who was an ardent supporter of the operation of tracheotomy.  Trousseau had previously convinced his fellow physicians that tracheotomy was the best method of creating an airway when suffocation was imminent, even with the low success rate. (12)

The main problem with Bouchut's "small tubes" is that they "did not adapt to the anatomy of the larynx and their sharp edges were a very traumatic cause of lesions to the mucosa and of intense pain."  (12) (also see 26,page 13)  Also of note, since the tube was short, it was barely positioned below the glottis (this would have allowed for air to leak around the tube resulting in diminished lung volumes).  In the end, "Bouchut and his operation were so bitterly criticised that he became discouraged and abandoned it altogether. So effectually was it crushed out that no further investigations were made in this direction for nearly a quarter of a century." (26, page 13)

Richardson's (21)

1867:  Richardson's Double Acting Rubber Bellows:  Benjamin Ward Richardson created a bellow system similar to Hunter's Bellows (although he may not have known of Hunter's Bellows). The original system took up a lot of room, so he invented the double acting bellows, which "consists of two rubber bulbs terminating in common tube that was called the nostril-tube."  One bellow supplied inspiration, the other expiration.  

1869: First intubation during operation:  Performed by Friedrich Trendelenburg (1844-1924) to prevent aspiration of blood and mucus during oral operations.  (13, page 91)

1875:  Blake cures poison victim:  Using a device similar to Richardson's Bellows, Blake connected a reservoir of condensed oxygen to it and treated a case of acute poisoning with success.  Before this time artificial respiration (often referred to as insufflation) was used mainly to treat neonatal asphyxia, but now the focus was also on treating adults.  The nozzle of the device was inserted into the nostril.  1

1878: The first elective intubation: William Macewan was a Scottish surgeon who, on July 5, 1878, performed the first elective intubation on a patient "with a flexible metal tube" who was not anesthetized.  "Once the tube was properly positioned, an assistant provided chloroform-air anesthetic via the tube.  Once anesthetized, the patient soon stopped coughing."  The physician lost confidence in his technique when a tube became dislodged and the patient expired.  His success and failures would become learning points for future surgeons or physicians attempting intubation.  It also should be known that, along with patient anticipation and fear, their was a lot of anxiety among physicians regarding this procedure.  Surely they wanted to help their patients, but they also didn't want to cause further harm by their experimentation.  Macewan, for example, practiced on cadavers prior to intubating any actual living patients.  (9, page 7)

O'Dwyer's Intubation Tube for a child 2-3 years old (23

1880:  The first effective endotracheal tube:  Dr. Joseph O'Dwyer (a pediatrician), and his fellow physicians at the New York Foundling Asylum, observed problems with trachetomy.  Once agian this occurred during an epidemic of diphtheria where too many children were dying due to suffocation from croup. (3, page 9-18)

Tracheotomy was a viable option as an emergency airway, but it was painful and bloody for children, and the end results were not always positive.  He decided another means of breathing for these children was necessary.   (3, page 9-18)

He at first trialed flexible catheters into the nasal passages, yet this didn't meet his satisfaction.  So he devised a tube to be placed into the larynx where it would remain.  In this way, he picked up where Bouchut left off.  By trial and error he tinkered with the device until it met his satisfaction.   (3, page 9-18)

O'Dwyer's set of five Tubes (26, page 19)

The device was made with a bivalve tube with a narrow transverse diameter, and about an inch long."  A shoulder on the upper end prevented the tube from slipping down (perhaps learned from Macewan's error).  By trial and error the tube transformed so the tube was a "plain tube of elliptical form about an inch in length.  (3, page 9-18)

He then played with longer tubes until he found the desired length.  The final tube used was made of brass and lined with gold, and was accepted by the medical community.  (See figures 2 and 3.)   (3, page 9-18)(also see 26, pages 18-21)

A complete set was included in a box, that included sizes for different aged children, an obturator, an introducer, an extractor, and a gag.   The length of the tubes in inches were 1.5, 1 3/4, 2, 2.25 and 2.5. (3, page 9-18)(also see 26, pages 18-21)

The obturator of the physicians choice is connected to the end of the introducer, and this is used to insert the tube.  If necessary a small thread could be inserted and tied to a hole on the outer edge of the tube to prevent it from going down the traches, and to facilitate removal. (3, page 9-18)(also see 26, pages 18-21)

The kit also came with a scale (see figure  5) which helped the physician determined appropriate depth of the tube according to age.  The scale is used like this: "The smallest tube reaches line 1, and is intended for children about one year and under. The next reaches line 2, and is for children between one and two years. The third size, marked 34 on the scale, should be used between two and four years. The fourth, marked 5-7, is for the next three years, and the largest tube is for children from eight to twelve."

O'Dwyer also designed larger tubes and equipment for adult intubation. (3, page 9-18)

1880:  The Fell-O'dwyer Apparatus:  Once O'dwyer intubated his patient's, he needed a mechanism to breathe for them.  This task fell into the hands of George Fell, who invented a t-piece.  One end of the t-piece was connected to the tracheal tube, and the other to bellows.  The bellows were used to provide positive pressure breaths.  Of course the problem here is it took a lot of manual labor to provide breaths for such patients.  Still, the technique provided physicians an opportunity to help their patients, both when a physician needed to create an emergency airway, and when surgeons needed to perform more invasive operations.  (9, page 7) 

O'Dwyer's introducer connected to obturator (23, page 16)

1887-1888:  George Fell's Apparatus (Hand Operated Bellows): In 1887 Dr. George Fell invented a system of bellows whereby the operator would use his hands to provide positive pressure breaths.  He connected the bellows to either a tracheotomy or face mask. He became the first to perform this procedure on a human in a case of poisoning. (6, page 283)  (22, page 3) In order to connect the apparatus to the airway, Fell invented a t-piece.  One end of the t-piece was connected to a tracheal tube or mask, and the other to the bellows.  (9, page 7)

Figure 5

1889: The first rubber endotrachal tube:  Thomas Annandale devised a tube made of Indian rubber that was connected from the tracheostomy to (a cap is attached to the trach for just this purpose) to a small tumbler filled with "a piece of absorbent wool at the bottom, upon which chloroform or ether is from time to time sprinkled."  This was significant because a similar material would be used by a later physician to create an endotracheal tube that would be commonly used for over 40 years. (27, pages 261, 838)

1891: The Fell-O'Dwyer Apparatus (Foot operated Bellows)  Once O'dwyer intubated his patient's, he needed a mechanism to breathe for them.  George Fell's apparatus must have worked, yet it needed to be fine tuned for ease of use.  He revised Fell's system so that breaths were provided by pressing down on a lever with his foot.  O'Dwyer preferred to connect his bellow system to an endotracheal tube.  O'Dwyer was concerned about over-distention of the lungs due not allowing enough time for expiration, and therefore recommended giving slow breaths, or 10-12 per minute. (6, page 283)

1891:  Concerns of Intubation:  By the late 19th century many of the same concerns physicians have today about intubation were considered.  One such concern being the ulceration of tissue due to pressure of the tube set upon it for a long period of time.  Tubes were generally taken out after six days with success, although in some cases were left in 12 days or longer. Dr. Rank, a German physician, ultimately recommended removal of the tube after 10 days, and if necessary, the physician should consider tracheotomy. Some physicians recommended extubation after the 5th day, which would be in line with modern protocols.  Feeding the patient was also a concern, and was either done with soft foods or liquids, or by nasalgastric tube.  It was recommended that if the tube was accidentally spit up that the nurse take advantage of the moment to try feeding the patient prior to re-introducing the tube (if the tube is still needed). (3, page 29-20)

O'Dwyer intubation kit as advertised to physicians in 1901.  (16, page 228)

1892: Dr. O'Dwyer makes pitch for intubation:  In 1892, and according to the New York Academy of Medicine,  Dr. O'Dwyer gave a presentation where he explained that poor statistics shouldn't discourage physicians from performing the procedure, as most studies are performed by "hospital staff, who did not remain on duty long enough to obtain the skill necessary to perform intubation successfully." (14, page 557)

He said:

"The operation of intubation is a difficult one, because it must be done very rapidly.  A period of ten seconds is not safe in some cases, and fifteen seconds would certainly produce apnea in many instances.  The necessary touch and skill require much practice, and this should be acquired on the cadaver until the tube can be inserted in different subjects in about five seconds. It is much easier to perform intubation in some subjects than it is in others.  After such prolonged practice, the operation may be done with comparative safety... No great amount of surgical skill is required to perform tracheotomy, but good nursing is a necessity.  Intubation, therefore, calls for a trained operator, and tracheotomy for a trained nurse."(14, page 557)

Here is another picture of O'Dwyer's Intubation kit. (26, page 27)

He noted that regardless of the challenges, "intubation has supplanted tracheotomy to a very considerable extent, especially in this country (the U.S.)."  O'Dwyer further noted that with his new improved equipment, he never finds a case in which he finds it impossible to insert the tube. (14, page 557)

1892:  Dr. Gay makes pitch for intubation:  Another physician, Dr. George S. Gay of Boston, said that "intubation is by no means perfect, but it possesses sufficient advantages to give it a permanent place in the treatmenet of acute laryngeal stenosis (narrowed upper airway caused by croup secondary to diphtheria).  Although it will never entirely displace tracheotomy, the former has some important advantages over the latter.  No anesthetic is required; there is no hemorrhage.  Unless one's early experience with intubation has been particularly favorable, he is likely to prefer tracheotomy.  The strongest advocates of intubation will be found among those who have had the largest experience with it.  The consent of the parents to perform intubation is more easily obtained, and the operation can be resorted to earlier." (14, page 557-558)

This shows the proper position of operator and assistant. 

The assistant holds the head "securely and slightly backward."

The gag should be introduced in the left angle of the mouth,

 well back between the teeth, and widely opened. The operator

 should then quickly seize the introducing instrument with the

 tube attached, hook the loop over the little finger of the left hand,

 and introduce the index finger of the same hand, closely followed

 by the tube" The tube should sit in the larynx. (26, pages 38-40)

1892: Dr. Jacobi makes pitch for intubation:  According to the Medical News, Dr. Abraham Jacobi said he performed many tracheotomies (between 600 and 700), but around 1887 he listened to a discussion at the New York Academy of Medicine in which he was "converted from trachheotomy to intubation."  He warned that, as noted by the Medical News,  "It is very easy to get the parents consent to perform intubation, but it is very difficult to get their consent to perform tracheotomy.  For this reason in many cases the latter operation is performed to late."  He notes that despite improvements in aeseptic techniques, it's still impossible to prevent dying due to sepsis infection of the blood). The Medical News also mentions that "Dr. Jacobi said that, although he is in favor of intubation, adn always recommends it, he has never performed the operation personally.  Thirty years ago he was a professed tracheotomist, and on one occasion he was told that he was a good enough man, but that he cut too many throats." (14, page 558)

1893: Cuffed Endotracheal Tube:  It must have also been discovered early on that air was leaking around the tubes, instead of inflating the lungs.  Likewise, some patients must have vomited when the tube was inserted past the gag reflex, and this would have caused aspiration pneumonia, which would spell doom for most patients back then.  Physicians must have sought some means of securing the airway around the tube. According to the 55th anniversary publication of the German Society of Anaesthesiology and Intensive care, Victor Eisenmenger became the first to use an endotracheal tube that had a cuff on the distal end of the tube that was connected by a pilot line to a pilot balloon.  Air was inserted with a syringe into the pilot line, and both cuffs would become inflated.  The physician would know the distal cuff was inflated when the pilot cuff was inflated. Such a system was soon adapted by other physicians.  (13, page 91)

This is a picture representing insertion of O'Dwyer's tube.
The dotted lines represent the outline of the operator's forefinger.
Yes, back then a finger was used to assist the endotracheal tube to
the desired location in the airway.  The proper tube should be
selected, attached to the introducer, and then introduced to the airwa.
 It was inserted under the tip of the epiglottis, and into the larynx
You  knew the tube entered the larynx when the patient coughs and
the breathing becomes easier.  If it enters the esophagus, breathing
will not become easier.  Once the tube is inside the larynx, the
tube should be disconnected from the introduces.  The tube
should then be pressed forward until it is positioned in the pharynx
Physicians were further warned that "no force should be used,
no anesthetic is required, and the operator should not require
longer than five to ten seconds.
The risk, as you might imagine, was getting bitten by the patient,
and inhaling the same air as the patient, and then getting
the same disease.  Some physicians sacrificed
their lives by attempting to save the lives of their
patients by this procedure.  (26, page 40-42)

1895: First use of laryngoscope:  A laryngoscope was invented to visualize he back of the airway, and was first used by Kirsetein in Germany (15, page 372)

1896: The Fell-O'Dwyer Apparatus modified:  Dr. Northrup recommended the Fell-O'Dwyer apparatus, and it was later modified by Tuller and Hallion of France, and later by Doyan.  Doyan's "apparatus consisted of 'duplex' bellows (for insuflation and suction) attached to an intralaryngeal cannula. (22, page 3)

1900:  Cuffed Endotracheal Tubes and laryngoscopes:  Around the turn of the century cuffed endotracheal tubes (ETT) were used with increased frequency.  A larygoscope was first described in 1855 using sunlight to see the vocal cords, and by 1913 a battery powered laryngoscope with an external light was invented.  This was refined so it had a handle with a battery and a light bulb at the end of the scope for easy visualization of the vocal cords.   (2)

1900: Oral intubation becomes popular: Initially the procedure of oral intubation must have been as nerve wracking to the physician as the patient and the patient's family.  However, as with anything, the more it was performed the more confident and competent the physician became in both recommending and performing the procedure.  According to a 1911 edition of the New York Medical Journal there must have been enough successes with the intubation by the mouth (per os) by 1900 that it had "found many followers."  (12, page 760)


1900:  Indications for intubation:  As more and more physicians became comfortable with laryngeal intubation, they began experimenting with the procedure both on cadavers and on real live patients.  The ultimate goal, of course, was to help patients survive diseases that otherwise would have taken their lives.  By 1911 some of the indications are mentioned in the New York Medical Journal: (12, page 760)

• Narcosis
• Operations (of the mouth, nose, throat and thorax) (12, page 760)

1900-1912:  Intubation technique improved: Frank Kuhn, a German physician, published a series of papers where he "described the techniques of oral and nasal intubation that he performed with flexible metal tubes composed of coiled tubing similar to those now used for the spout of metal gasoline cans."  (11, page 7)  

The tubes were of his own design. (13, page 91) As a local anaesthetic to prevent the gag reflex he used cocaine.  He introduced the tube into the airway with a metal stylet.  He used his the index finger of his left hand to lift the tongue and the glottic tissue, and used his right hand to insert the tube through the vocal cords.  While cuffs were used by other physicians to seal the airway, he preferred to have it sealed by "positioning a supralaryngeal flange near the tube's tip before packing the pharynx with gauze."  (11, page 7)  (13, page 91)(also see 22, page 3) 

To see a very good picture of Kuhn's procedure check out this link.  

1902: O'Dwyer apparatus modified again:  This modification was made by R. Matas who 'Constructed an apparatus in which a modified O'Dwyer tube was connected with an automatically acting pump.  The pump contained originally two independent metal cylinders for inspiration and aspiration.  However, the first experiment made on a dog convinced Matas that the suction force, exercised by the aspiration cylinder, does damage to the lungs, and he eliminated that part of the apparatus. (22, page 3)

1913:  Modern laryngoscope invented:  A better laryngoscope as invented by Jackson, and it was later improved by Miller and Mackintosh (see below) (14, page 372)

1914-1918: Magil invents blind intubation:  During WWI Dr. Magill performed a variety of facial reconstruction surgeries. He discovered that in order to do such surgeries the patient had to be intubated.  Along with Stanley Rowbotham, he developed a method of tracheal intubation.  He blindly inserted one tube of gum elastic design into one nostril.  In this way he coined the term "blind intubation."  (24, pages 8, 753)

There were two problems with this system.  One was that anesthetic gas was escaping the tube, and the operating physician was inhaling this gas. Obviously, this affected his work.   The other was that blod and other debree from the operation would fall into the airway when the tube was pulled.  Obviously, this was detrimental to the patient.  So a two-tube system was developed.  One tube was blindly inserted into a nostril into the larynx to breathe and to apply the anesthetic, and the other through the mouth into the pharynx to provide for the escape of gases.     (24, pages 8, 753)

He became so proficient at his method that students from all over came to watch and learn his method.  While he taught his method, other physicians continued to have trouble inserting the tubes due to patient agitation, while Magill did not.  Magill had a secret that he refused to tell the students: that he used cocaine as a local anesthetic to the throat.  (25, page 110) 

The rubber endotracheal tubes used by Magill were standard for the next 40 years until being replaced with plastic tubes. (24, page 8)

1920: Magill Forceps introduced:   In order to guide the nasal tube into the airway, Magill used forceps that still bear his name (Magill Forceps) (15, page 372)(24, page 8)

1926: Guedel experiments with cuffed endotracheal tubes:  Noting the need to protect the lower airway from secretions and surgical debris, Arthur Guedel (1883-1956) performed experiments with using a cuffed endotracheal tube.  His cuff was made out of rubber. His experiments also determined that the best place to position and inflate the cuff was just below the vocal cords.  This, he found, was the best way of protecting the airway during intubation.  One this task was accomplished, he aimed to encourage stubborn American physicians that intubation of the benefits of intubation.  (24, page 8)

1926: Guedel inspires American physicians to intubate:  While European physicians intubated on a regular basis during operations, American surgeons used other means.  Noting the benefits of intubation, Arthur Guedel put on a show where he went around the country with his dog named Airway.  He would anesthetize and intubate his dog, and then submerge it under water.  Just as the audience suspected the dog was dead, he would pull it from the water, extubate it, and the dog would shake off the water and run off.  These shows became known as the Dunking Dog Shows proved that intubation not only allowed the physician to breathe for the dog, but the inflated cuff prevented water from getting into the dogs lungs.  These efforts worked, as American physicians soon became proficient in intubation. (25, page 111)

1930:  Oral Airway Introduced:  Ralph Waters (1883-1979) introduced the flattened oral airway, and it was later modified by Guedel by fitting the oral airway with a "rubber envelope in an attempt to reduce mucosal trauma." (24, page 753)

1932:  One lung intubation introduced:  Ralph Waters accidentally allowed an endotracheal tube to slip all the way into a patient's lungs, and he inflated the cuff.  In this way he learned that one lung could be intubated with a long endotracheal tube while the other was operated on.  This made it possible to do lung operations.  (24, page 8)(25, page 111)

1942:  Anesthesia during intubation: By the 1880s intubation was being increasingly used for children with airway stenosis secondary to croup secondary to diphtheria.  As a physician observed that the patient was going to suffocate to death unless he did something, the choice was offered to the parents: intubation or tracheotomy?  (2, page 227) (19, page 1674)

Intubation must have presented as the best option in many cases, as the procedure would avoid a cut of the throat.  A problem that continued was the procedure caused quite a bit of anxiety on the part of the patient, as you might imagine.  If the child fought the efforts of the physician, this could make the procedure very difficult to perform. (2, page 227) (19, page 1674)

Cocaine was occasionally used as a local anesthetic to prevent the gag reflex, and general anesthetics were occasionally used to paralyze the patient, although these were only used if the physician was familiar with them and comfortable with their use.  (2, page 227) (19, page 1674)

 In 1942, Harold Griffith, A Canadian anesthesiologist, made a major breakthrough in this regard on January 23, 1942, when he and his assistant, Dr. Enid Johnson (also an anesthesiologist) used Curare to paralyze a patient prior to intubation.  He used it as an anesthetic in 23 operations, and wrote a report on his successes with it.  (2, page 227) (19, page 1674)

This was a major breakthrough because it allowed the surgeons to sedate and ventilate patients during the operation.  (2, page 227) (19, page 1674)

WWII:  Intubations proficiency increases worldwide:  In preparation for the traumas generally associated with battle wounds, anesthesiologists practiced and became very proficient at performing the procedure of intubation.  The methods learned became standard practice, and oaver time intubation training became a regular part of a physician's training.  (25, page 753)

1964: Plastic endotracheal tubes introduced: They were actually made of polyvinylchloride (PVC) with an inflatable cuff. Rubber tubes tend to harden when exposed to body temperature.  PVC tends to soften at body temperature, and is therefore less likely cause damage to tissues of the airway.  The tubes are also clear and opaque.  They come with markers so caregivers know how far down the tube is inserted.

1970:  High volume, low pressure cuffs introduced:  Previously, cuffs were low volume high pressure.  When inflated, these cuffs came into contact with very little area of the trachea, and created a great seal.  However, due to the high pressure, risk of cutting off circulation and causing necrosis was high.  High volume, low pressure cuffs would come into contact with more tracheal tissue, although the lower pressure was less traumatic.  Surely the cuff pressure would have to be minimized, and the cuff may need to be rotated up or down 1-2 cm on a regular basis to minimize tissue damage, yet this was a much better set up than the older cuffs. The drawback is the seal is not ideal.

Conclusion:  So you can see that physicians were slow to begin using intubation, although experiments by the few, in an attempt to help their patients, resulted in both an improvement in the technique used and the equipment available.  By the 1940s intubatoin during surgery would become standard, and by the 1950s the procedure became standard in across the medical spectrum, including at on the scene of an accident and emergency rooms.

Likewise, while fireside bellows remained the preferred method of providing breaths through the endotracheal tube, the quest was ongoing to find a mechanical device that would provide breaths in a means that was less laborious for the provider, and safer for the patient.

References:

1. Price, J.L., "The Evolution of Breathing Machines," Medical History, 1962, January, 6(1), pages 67-72; Price references The Bible, Kings, 4: 34 
2. Szmuk, Peter, eet al, "A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age," Intensive Care Medicine, 2008, 34, pages 222-228
3. Ball, James B, "Intubation of the Larynx," 1891, London, H.K. Lewis
4. Woollam, C.H.M., "The development of apparatus for intermittent positive pressure respiration," Anaesthesia, 1976, volume 31, pages 537-147
5. Previtera, Joseph, "Negative Pressure Ventilation: Operating Procedure (Iron Lung)," Tufts Medical Center, Respirator Care Programs, http://160.109.101.132/respcare/npv.htm, and http://160.109.101.132/respcare/ironlung.htm, accessed February 27, 2012
6. Tissler, Paul Louis Alexandre, "Pneumotherapy: Including Aerotherapy and inhalation...," 1903, Philadelphia, Blakiston's sons and Company, page 284,5
7. Lee, W.L., A.S. Stutsky, "Ventilator-induced lung injury and recommendations for mechanical ventilation of patients with ARDS," Semin. Respit. Critical Care Medicine, 2001, June, 22, 3, pages 269-280
8. Sperati, G., Felisati, D., "Bouchut, O'Dwyer and laryngeal intubation in patients with croup," Acta Otorhinolaryngol Ital, 2007, 27 (6), 320-323
9. Barash, Paul G,  Bruce F. Cullen, Robert K. Stoelting, Michael Cahalan, M. Christine Stock, editors, "Clinical Anesthesia," 6th edition, 2009, China, Lippincot Williams and Wilkins
10. Subramaniam, Rajeshwari, "A primer of anesthesia," 2008, MO, Jaypee Brothers Medical Publishers
11. Barash, Paul G., Bruce F. Cullen, robert K. Stoelting, Michael k. Cahalan, M. Christine Stock, "Clinical Anaesthesia," 6th edition, 2009, Philadelphia, Lippincott
12. Foster, Frank P., editor, "Book Notices," New York Medical Journal, volume 94, New York, A.R. Elliott Publishing Co. 
13. Schuttler, Jürgen, editor, "55 years: German Society of Anaesthesiology and Intensive Care Medicine," 2012, Germany, Springer
14. Gould, George M., editor, "Society Proceedings: New York Academy of Medicine: Stated Meeting, Thursday Evening, October 20, 1892," The Medical News, A Weekly Medical Journal," July-December, 1892, Vlolume LXI, Philadelphia, Lea Brothers and Co., pages 557-558
15. Hagberg, Carin A., "Benumof's Airway Management," 2007, Philadelphia, Mosby
16. "Blees-Moore Instrument Company: surgical instraments," 1901, St. Louis, MO, Burton and Skinner Print
17. Miller, Ronald D., editor, "Miller's Anesthesia," 7th edition, volume 1, 2010, Philadelphia, Churchill Livingstone Elsevier
18. Vogel, Virgil J., "American Indian Medicine," 1970, London, Oklahoma University Press
19. Wheeler, Derek S., Hector R. Wong, Thomas P. Shanley, editors, "Pediatric Critical Care Medicine: Basic Science and Clinical Evidence," 2007, London, Springer
20. "Drowning: Historical-Statistical Methods of Resuscitation," no author nor editor listed, Published by Lungmotor Company, Boston, Massachusetts, 1920
21. Hughes, Martin, Roland Black, "Advanced Respiratory Critical Care,"  2011, New York, Oxford University Press; material from section 3.1: "Invasive Ventilation Basics: Development of Invasive Ventilation (history)."
22. Meltzer, S. J., "History and analysis of the methods of resuscitation," Medical Record: A Weekly Journal of Medicine and Surgery, July 7, 1917, Volume 92, Number 1, New York, 
23. The Forty Ninth Annual Report of the Royal Humane Society, For the Recovery of  Persons Apparently Drowned or Dead," 1823, London, 
24. Barash, Paul G. Bruce F. Cullen, Rober, "Clinical Anesthesia," 2009, Philadelphia, Lippincott
25. Friedman, Meyer, Gerald W. Friedman, "Medicine's 10 Greatest Discoveries," 1998, Yale University
26. Waxham, F.E., "Intubation of the Larynx," 1888, Chicago, published by Charles Traux (Waxham was an early proponent of intubation for diptheria and croup. 
27. Gould, George M, "American Year-book of Medicine and Surgery," 1899, Philadelphia, W.B. Saunders
28. Curry, James, "Observations on Apparent Death from drowning, hanging, suffocation by noxious vapours, fainting-fits, intoxication, lightning, exposure to cold, & etc., and an account of the means to be employed for recovery. To which are added the treatment proper in cases of poison, with caution and suggestions respecting various circumstances of sudden danger," 2nd edition, 1815, London (the 1st edition was published in 1792)

760-370 B.C.: Hippocrates redefines medicine

What did Hippocrates really look like. Some historians speculate

most busts of him were made after his lifetime. Prioreschi said:

"It is highly probable that physicians of the Periclean Age wore

their hair and beards as much like the figures of Jove or

Aesculapius as possible, and were otherwise not lacking in the

self sufficiency which characterized the Greeks of the period.

We may therefore infer that the supposed portraits of Hippocrates

are only variants of the busts of Aesculapius. (1, page 92)

There are only a few people in our history whose contributions were so significant they end up being deified. One such man was the great physician Hippocrates.

While he may not have done all the work himself, his name is on one of the first and most significant medical treaties of all time: the Hippocratic Corpus. It would mold the image of Hippocrates, establishing him as the greatest physician of his time and of all time.

The Hipporcratic Corpus, often simply referred to as the Corpus, is a compilation of over 60 medical treaties which are essentially a compilation of all the knowledge learned by Hippocrates from his "immediate ancestors," said medical historian Edward Meryon in his 1861 book "A history of medicine." (6, page 22)

The name Hippocrates is a reflection of all the great physicians that formed Greek medicine.  The Corpus is a reflection on the era he was born into.

What era was Hippocrates born into?

Pericles (495-429) was in charge of the Athenian
Military during the Pelopannesian War, and
became a leading statesman and orator for Athens. 

Hippocrates was born on the island of Cos, near modern day Turkey, around 460 B.C., during the peek of Athenian democracy, an age when Pericles (495-429) walked the earth as a famous Greek general, statesman, and orator.   (1, page 21-22) (2, page 86)

It was an era of ancient Greece where the citizens of Rome had little work to do, and therefore had plenty of time to read, learn, and think.  This was made possible because most citizens had many slaves who did all the work for them.  This, it is said, gave rise to the Age of Philosophers in ancient Greece.

Of this time in our history, medical historian Fielding Hudson Garrison, in his 1922 book "An introduction to the history of medicine," said:

Never before, or since, had so many men of genius appeared in the same narrow limits of space and time. (2, page 86)

Medical historian Edward Meryon, in his 1861 history of medicine, said:

He lived at the most remarkable epoch of intellectual development, having as contemporaries the philosophers Socrates, Plato, and Xenophon; the statesman Pericles; the historians Herodotus and Thucydides; the poets Pindar, AEschylus, Euripides, Sophocles, and Aristophanes; and last, though not least, the sculptor Phidias. (1 page 22) (also see 8, page 126)

Garrison said he was born into an era where the primary role of the physician was "either an associate of priests in times of peace, or a surgeon in times of war."  (9, page 87)

He was also born into an era where medicine was a blend of superstition and mythology, and was esoteric wisdom known only to the priest/ physicians at the Asclepions.  Those who were sick would spend time among the priest/physicians there, and the remedy would be revealed, and often involved magical elements such as incantations and amulets.  Yet these Asclepioins were not hospitals per se, merely places where the sick could learn the healing wisdom from the god Asclepius.

Those who were sick might also summon for a physician, men who, like the priest/physicians, were trained at the Asclepions. Yet these physicians were free from the bonds of the Asclepions, and were able to reach out to the general population, most often visiting their patients at their homes.

Medical historian Max Neuburger said:

From Homer's time (about 800 B.C.) and onward poets and historians make mention of lay physicians who freely exercised their profession untrammeled by temple medicine. In very early times the custom arose for communities to appoint official physicians whose duty it was, for a fixed salary, to to attend the poor gratis, to make the necessary sanitary arrangements in the presence of epidemics, and as experts to give evidence in court: it is equally certain that a medical corp accompanied armies and fleets... and that Greek physicians accepted posts as court court and personal medical advisers to foreign princes. (8, page 97)

Natural medicine made it's way into the priesthood at the temple of Cos at an early date, and such medicine was learned by physicians who would then take their medicine outside the temple.  So this provided more options for the sick.  For those who were perplexed by the puerile medicine at the temples, they could summon a physician who practiced natural medicine.

Neuburger said that over time, particularly at Cnidos and Cos, there was a complete separation at the Asclepiades of all temple magic. So the priests and their magic ultimately gave way to physicians and their natural remedies. In the meantime there was a mixture of both types of medicine. (8, page 99)

Once summoned, the physician would then pack his bag of medical supplies and travel to the sick person's home.  Of these medical bags, Neuburger said:

On medical journeys a portable case was taken with indispensable instruments, bandages, ointments, plasters, emetics and purgatives. Such cases have been discovered (8, page 98)

Neuburger said there were also medical homes with sick rooms where the sick could see a physician for temporary treatment, although these homes were mostly reserved for people who required surgical intervention, such as for fractures and open wounds.  (8, pages 97-98)

Since there were no medical treaties at the time, there were no regulations and no standards as to how a physician was instructed. For this reason medical studies varied from one school to the next.

The result was often physicians who were ignorant of their trade, rough with their patients, and painful by their remedies. Many Greeks eventually recovered from their ailments without the guidance of a physician, and therefore it was often suspected that when a physician cured he was merely lucky.

As Hippocrates would later describe, this situation was exacerbated...

...under the pretext that physicians never undertake the care of those, who are already overpowered by disease. They say, that he cheerfully attends on such as would recover without him—but not a step will he take in behalf of those who are most in need of his assistance. If there was an art of medicine, they moreover say, it ought to cure these as well as the former. (3)

So it was no wonder that the sick would prefer to travel long distances to an Asclepion, or stay at home, tucked in their cozy beds, waiting their fate, as opposed to risking a call for any random physician.

What family was Hippocrates born into?

Meryon said that most of what is known of the school of Cos, and later about Hippocrates himself, comes from biographies written after the death of Hippocrates.  From these we learn he was the "scion" of a family of physicians at the school of Cos "which had followed the pursuit of medicine at least 300 years." (1, page 21-22)

These physicians were well aware of the poor image of physicians.  They believed this poor image was due to the practice of physicians who graduated from the school of Cnidron.  This school was about 20 miles from Cos, and these physicians didn't care about the poor image, and did little if nothing to improve it.

Medical historian Edward Withington, in his 1894 book "Medical history from its earliest times," said physicians at the school of Cnidron were aggressive with their treatment. He said this is exemplified by the their motto: (4 ,page 52)

"Accurate diagnosis and vigorous treatment."  (4 ,page 52)

Medical historian Max Neuburger said Cnidian physicians focused on diagnosis, and then finding cures for these. He said: (8, page 114)

Their therapeutic methods, in accordance with their ideas upon localisation, appear to have been mostly topical, more radical than expectant and individualising. With knife and cautery to hand they were nothing loth to perform excision of a rib in empyema or nephrotomy in renal abcess and did not hesitate to order excessive purgation, dietetic cures or exhaustive walking exercise. (8, page 115)

Some of their therapeutic methods included: (8, page 115)

• Injection of fluids in the air passages to produce coughing
• Inhalations to promote the expulsion of mucus or pus from the lungs
• Application of leather bags for the purpose of fomentation, swinging movements, etc. (8, page 115)

He wrote about a case described by Caelius Aurelianu in which a prominent physician named Euryphon at the school of Cnidus (a contemporary of Hippocrates) "tries to show that pleurisy is an affection of the substance of the lung."  (4 ,page 52)

Withington said Aurenlianu described the patient as being "thin as a skeleton, his legs like reeds, his chest still full of pus, and his ribs covered with scars from the cautery irons of Euryphon." (4, page 52) 

Neuburger said the writings of Euryphon, all of which have been lost, are believed to have influenced some Hippocratic writings. (8, page 115)

Physicians of Cnidron were also known to take bribes to use poisons to kill the enemies of their patients. To the physicians at Cos, this must have been the culmination of what was wrong with the profession, and what their potential patients must have feared the most.  So their aim was to change this image.  

The physicians at Cos frowned upon the act of using medicine to kill.  They frowned upon the act of being rough with their patients, and using aggressive treatment that was painful, and sometimes killed.  They were very concerned about the image of the profession and they aimed to improve upon it.  They aimed to create a kinder, gentler approach to medicine. This approach is later exemplified by the Hippocratic Treaties "On the Art of Medicine." (3)  

Hippocrates described a family of physicians who impressed upon their students that good bedside manner was essential.  They encouraged the use of gentle hands and gentle remedies. They were encouraged to assess the patient and his surroundings, and to "compare his disease with such as he had previously seen, either the same, or approaching thereto, and which he has cured by the admission of the patient himself." (3)

Like the Cnidian physicains, Con physicians performed accurate assessments, and even accurately described diseases and their treatments.  But the Con were more interested in prognosis than diagnosis, with their cures being based on this prognosis. (8, page 117)

Born into the Con family of physicians was Hippocrates II, a man history knows as the great Hippocrates.

Who was Hippocrates?

Hippocrates II was the son of Heraclides, and the grandson of Hippocrates. Some historians said he was a direct descendant of Asclepius, and perhaps it was for this reason that Galen (2nd century A.D.) would later say of Hippocrates that "his writings should be reverenced as the voice of a deity." (6, page 21)(also see 5, page 23)(also see 6, page 203-204)

John Watson, in his 1856 book "Medical history from the earliest times," said was from his father that Hippocrates learned much of his skill, technique and work ethic.  As a child he also had access to the "ablest masters in science and philosophy," and all the best physicians in the world. (5, page 46)(6, page 204)

Watson said that after the death of his father, he traveled to many countries before pursuing his profession in Macedonia, Thrase and other parts of Greece before settling in Thesally where he spent the later portion of his career.  He probably also taught at the School of Cos. In fact, some accounts have him starting the school.  (7, page 46)(8, page 86)

Neuburger said religion prohibited the examination of the internal organs of the human body for the purpose of science.  The only time a person's insides could be examined would be by the wounds obtained during fights in the gymnasium or on the battle field, or during the rare surgery that was performed.  For this reason, Hippocrates must have spent some time in the gymnasia, either as a student or as an observer.  (8, page 150, 156)

Physicians also spent time examining the naked bodies of the men, and so they would have learned, by observation and palpation, what was normal and what was abnormal.  By palpating abdomen's they would have learned what what normal and abnormal abdominal organs, such as the liver and spleen, felt like.  (8, pages 146, 150)

The only other means a physicains might have learned anatomical knowledge was by dissecting animals, or spending time in slaughter houses or watching sacrifices.  (8, page 150)

So it was unlikely that Hippocrates observed an autopsy, although highly likely, perhaps with the guidance of his father, that he spent time at slaughtering houses, or observing sacrifices, or observing surgical cases, in order to obtain anatomical knowledge.  It's also highly probable that he spent time in the the gymnasium at Cos to observe his father at work, but also to learn about the human body.     

Neuburger said:

With regard to the respiratory tract, the Hippocratists knew the trachea, epiglottis and bronchi, and described the lungs as having five lobes... The circulatory system is described in the various writings in a most confused manner.  The starting-point was at first supposed to be the head, later the aorta and vena cave, which were thought to spring from t spleen and liver; according to the book De morbo sacro, all arteries enter the heart.  

He would have learned that the trachea, bronchi, and arteries were hollow and contained air.  He would have learned various bones, joints, bone marrow, and sutures of the skull.  Knowledge of the viscera (heart, liver, stomach, esophagus, intestines, liver, bladder, spleen, and kidney was "scanty," said Neurburger, although he would have learned what was known about them. (8, page 151)

He would have learned of the nervous system, but sometimes nerves were confused with tendons, said Neuburger.  He would have learned about the four humours, the four qualities, and the four elements, and that their balance was what maintained health, and their imbalance caused maladies.  (8, page 152)

He would have learned about a vital principle that was inhaled by the pneuma (breath), and that the "fundamental principle of life is the 'inherent' warmth of the body which has its seat in the left heart. Under the influence of this inherent warmth elementary fluids of the body are formed from food, and from variable admixture of these fluids solid parts of the body are formed." (8, page 152-153)

Organs are "built up" by nutrients obtained from the blood, which was created in the liver, warmed in the left ventricle, and circulated by means of the beating heart through the veins.  Cool air was taken in by the lungs to cool the heart.  (8, page 153)

He learned that the pneuma originated in the heart, or brain, and circulated through the body from one of these organs.  This pneuma would have been responsible for sensation and movement.  The brain may have been responsible for many of the ailments of the body, including diseases of the lungs, colds, catarrh (inflammation), etc. (8, page 153)

Of this, Neuburger wrote:

The brain is, for the most part, looked upon only as a gland, as the seat of cold and phlegm, entrusted with the task of attracting to itself the superfluous water of the body.  (If, in the functions, a disturbance sets in, abnormal accumulations of phlegm occur in other organs, i.e. catarrh.)

When an imbalance of the functions of the body occurs, such as an imbalance of the humours, the brain loses its ability to control the flow of fluids to it, and excessive phlegm flows to one or another organ of the body. For instance, excessive phlegm flowing to the lungs causes asthma, pneumonia, pleurisy, empyema, and inflammation catarrh (inflammation), or your common cold.

So through his studies he would have learned the basic anatomical structures of the body, and how they worked together in unity to create life, maintain health, and restore health.  He would have learned how nature assisted in this process.

Thomas Bradford, in his 1898 book "Quiz questions on the history of medicine," said that, at the school of Cos, Hippocrates would have learned from the theories and cures recorded on the stone tablets, or votives, that were stored there.  (5, page 23)

Bradford said he participated in...

"...careful study of the medical records found in the votive offerings that hung in great profusion about the walls of the Aesclepiads.  He soon began to have a reputation as a physician, and his name was known not only in Greece, but in foreign courts also. (5, page 23)

He used the wisdom he learned from his father, at the school of Cos, and from the sages during his travels abroad, to become a very gentle and skillful physician. He would win the hearts of both his patients and his fellow physicians, thus improving the image of the profession, said Withington (4, page 50)

References:

1. Meryon, Edward, "The History of Medicine," Volume I, 1861, London,  (6)
2. Garrison, Fielding Hudson, "An introduction to the history of medicine, 1922, (9)
3. Hippocrates, "The Art of Medicine," Section I, Treaties III, translated by John Redman Coxe, "The writings of Hippocrates and Galen," 1846, Philadelphia, Lindsay and Blakiston (10)
4. Withington, Edward Theodore, "Medical History from the Earliest Times: A Popular History of the Art of Healing," 1894, London, The Scientific Press. (3)  (7)
5. Prioreschi, Plinio, "A history of medicine: Primitive and ancient medicine," v (1)
6. Watson, John, "The Medical Profession from the Earliest Times: an anniversary discourse delivered before the New York Academy of Medicine November 7, 1855," 1856, New York, Baker & Godwin  (4)
7. Sigerist, Henry, "A History of Medicine," volume 2, 1961, Oxford University Press  (2)
8. Neuburger, Max, writer, "History of Medicine," 1910, translated by Ernest Playfair, Volume I, London, Oxford University Press

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.)