1654: Bennet describes the inhaler

The Bennett Inhaler (3)

While the inhaler isn't invented until the 19th century by Dr. Stern and Dr. Mudge, Dr. Christopher Bennett (1617-1655) is the first to draw up an illustration of an inhaler for the medical community in his book "Theatri Tabidorum," that was published in 1654.  His was essentially the first method of inhaling medicine aside from primitive methods such as inhaling smoke from a pipe.  (1, page 173)

Bennett was an English physician who had tuberculosis.  He "gave us four woodcut drawings of an inhalation device, with measurements enabling the reader to have their own inhaler made.  The treatment was balsam.  There is no evidence that Bennett's inhaler was ever manufactured.  Bennett succumbed to tuberculosis the following year."  (2, page 530)

He was only 38 when he died.  (3)

References:

1. Korting, Monika Schafer, editor, "Drug Delivery," 2010, Germany, Springer-Verlag Berlin Heidelberg
2. Smyth, Hugh D.C, Anthony J. Hickey, "Controlled Pulmonary Drug Delivery," 2100, Springer New York Dordrecht Heidelberg London
3. Sanders, Mark, "Bennett's Inhaler,"  http://www.inhalatorium.com/page162.html, the picture is also compliments of Sanders.  

1976: How to treat asthma?

By 1976 asthma physicians have a much better grip on this disease called asthma.  The age old theory that an asthma attacks occur when one is exposed to an asthma trigger is now engraved in stone.  The reaction is contraction of the airways that results in air trapping and trouble breathing.  The other age old theory that asthma is all in your head, starts to fade away.

Yet it's still a very stressful time for asthmatic children and their parents.  There are still mysteries about the disease, and fears that medicines that help adults will harm children.  The basic plan of attack is to treat acute symptoms.  If you are having an attack you're to use your rescue inhaler (which was Alupent back then) and to start taking your inhaled corticosteroid (which was beclomethasone).  

There was a fear abounding that if you took your inhaled steroid every day it would cause the same side effects that taking systemic steroids cause.  So I imagine it was based on this fear that one of my discharge papers from a hospital discharge in 1981 was this:  "Use your Vanceril (Belclomethasone) until you start to feel better, and then use it when you have trouble breathing." 

There were other medicines, such as theophylline and Alupent syrup.  These were the medicines I was prescribed.  My doctors were probably scared that my heart wouldn't be able to take the Alupent, so they never prescribed it for me.  I think this was a grave mistake that resulted in many miserable nights for me and other asthmatics like me.  

Because doctors were scared, this lead many moms and dads to go to bed at night worried that they would have to get up in the night to watch their child suffer.  And there were asthmatics like me who suffered and didn't tell their parents because they didn't want to bother them.  Or, perhaps we suffered alone because we were simply children and didn't know any better.  We were so used to having asthma symptoms it was just a normal part of life for us.  

I think the staff of Prevention Magazine say it best when they wrote the following (1, page 124):

In hundreds of thousands of homes across the United States, parents go to bed each night fully aware that they might be awakened in the hours before dawn by a child wheezing and gasping for breath.  No matter how experienced they become in the ways of an asthmatic child, parents never really get over the terror of these moments.  To forestall further asthma attacks, they will consult one doctor after another, move out of the state, buy expensive drugs and special foods.  They reluctantly forbid their child to play outdoor games and veto the purchase of a family pet that could trigger future attacks.  

Yet parents who are poorly educated missed the signs not realizing their lack of asthma wisdom is the problem.  Doctors are unable to help because they are likewise in the dark regarding the latest research. At this time, the most well educated physicians were those associated with research hospitals such as National Jewish Hospital/ National Asthma Center (NJH/NAC) in Denver, Colorado.

The wisdom of this era was close to being complete, but not quite there yet.  In order get the best asthma relief, asthmatics would have to visit one of the leading asthma hospitals, such as NJH/NAC.  Regional doctors simply weren't up to speed, and not quite able to help parents help their children to tackle the asthma beast.

In the meantime, for those asthmatics unable to gain control by seeing a regional physician, and those unable to seek the asthma experts research hospitals, they continued to suffer.  As they are forced to watch their children suffer, parents suffer to.

References:

1. "The Encyclopedia of Common Diseases," by the staff of Prevention Magazine, "What makes children asthmatic?" 1976, United States, page 124

1778: John Mudge invents the inhaler

While he wasn't the first to use the concept of inhaler, not even the first in his own era (Dr. Philip Stern says he invented his inhaler in 1768),  Dr. John Mudge is often given credit for both the invention of the inhaler and the term "inhaler."


A wood carving of Mudge's inhaler from Dr. Cohen's 1876 book

Dr. Stern invented an inhaler, which basically used the power of steam that was inhaled through a pipe.  Yet, for whatever reason,  Dr. Stern wasn't accepted by the medical community.  So it's Dr. John Mudge who gets all the credit.  It's Dr. Mudge who's mentioned in most medical books, and medical history books, and given credit as the inventor of the inhaler.

Mudge invented his inhaler and advertised it in his book, "A Radical and Expeditious Cure
for a Recent Catarrhous Cough," published in 1778.  The year 1778 is also supposedly the year he patented his inhaler, for which reason it's often referred to it as "Mudge: patent," although no record of a patent was ever reported. (1, page 257)

Mudge's inhaler was mentioned in various magazines and books directed to the medical profession during the 19th century, including the book"Inhalation in the treatment of disease: it's therapeutics and practice" by Dr. Jacob Solis Cohen. 

Cohen provides for us the above wood carving, plus a nice description of the inhaler. He describes it as a simple pewter jug with a hollow handle with holes in it (f) to allow for the free flow of air so steam can be inhaled.  It also had a lid with two perforations.  Over one (a) a grid with a one way ball-valve made of cork can be slid over to allow air to exit but not enter.  Into the other (c) is inserted a long, flexible tube (d) that acts as a mouthpiece (e). The patient simply places his lips around the mouthpiece, inhaling the steam.

The patient can inhale simple steam, or medicated steam as desired or prescribed by a physician.  Thanks to the free flow of air from holes in the handle, and the egress of air through the hole with the grid, it was the first inhaler with a mouthpiece to allow the patient to inhale and exhale through the inhaler. 

How to use it is best described by Cohen:

 "The mug being filled to two-thirds of its capacity, the water of course rises in the handle to the same level; and, therefore, when the patient inspires through the flexible tube, the air rushes through the handle of the mug into the water, and out through the inhaling-tube. When the patient expires through the tube, the air of expiration passes into the free space beneath the cover, and is expelled out of the second perforation in the cover, lifting the cork-valve in its egress." (2, page 20)

It was a great invention for its time, and was marketed into the 20th century. 

References:

1. Bennion, Elizabeth, "Antique Medical Instruments," 1979, 1980, California, University of California Press
2. Cohen, Jacob Solis, "Inhalation in the treatment of disease: it's therapeutics and practice," 1876, Philadelphia, Lindsay and Blakiston

Further rading:

1. Sanders, Mark, "Mudge Inhaler," Inhalatorium.com,  http://www.inhalatorium.com/page57.html, you can also review a slide show presentation on "Pioneers of Inhalation," by Mark Sanders.  Sanders has a collection of antique inhalers and nebulizers he has graciously shared with us on his website.  Mr. Sanders also provided permission to use the photo attached to this post.  
2. Mudge, John, "A radical and expeditious cure for a recent catarrhous cough: preceded by some observations on respiration with occasional and practical remarks on some other diseases of the lungs," 2nd edition, 1779 (original edition was in 1778), London, printed by E. Allen, Fleet Street

1768: Dr. Phillip Stern writes book for asthmatics

So it's the year 1767 and you have asthma.  For the price of just one schilling you can purchase a copy of Dr. Phillip Stern's book called, "Medical advice to the consumptive and asthmatic people of England."  It's one of the first books ever written specifically for you, the patient.

Now there's a catch here of course.  He apparently admits to writing the book directly to the patient because he apparently had a falling out with his fellow physicians.  Perhaps it was because his ideas are rejected by the medical profession.  Or perhaps it was because he rejects the methods of the medical community and postulates his own.

Many historians presume his ideas were rejected by the medical community specifically because he wrote his book to the public, and not to physicians (which was the norm back then).  And, to be honest, Dr. Stern does use some harsh wording when referring to his physician contemporaries.

Regardless, he provides a brief anatomical review of the heart, vessels, diaphragm and respiratory system.  He describes how the lungs are "divided into two principle lobes which are inclosed in two distinct bags, formed by a membrane called the pleura; so that the right and the left lobe of the lungs have not the least communication."

Now this separation of the two lungs is important, because when a portion of one lung becomes diseased or dies, perhaps due to pneumonia or consumption, the patient can continue to live.  He writes:

"But here it may naturally be asked, how it happens, when a part of an organ, so indispensably necessary to life, is destroyed, that the patient does not immediately die.  I answer that Nature, in this instance, has been particularly kind to us; for the two lobes of the lungs, have no communication, are not immediately affected by each other's diseases; besides, every minute branch of the same lobe is so contrived, as to perform its office independent of the rest; therefore every single vessel continues to receive and return its portion of air, till it be actually destroyed." (1, page 11)

So the lungs are resilient to disease, and parts of them can continue to work regardless of the diseased parts.  This is good when it comes to diseases like pneumonia or consumption which can close off portions of the lungs to the reception of air.

The majority of Sterns book describes the disease consumption, his theories as to the pathology of the disease and his perceived remedies.  It isn't until we get to page 33 that we learn about asthma, "that disorder, the chief symptom of which is difficulty of breathing.  It is either continued or by fits."  (1, page 33)

Regarding the cause he writes: "Now, though the cause of the disease is frequently in the lungs, yet it is sometimes owing to a morbid affection of some of the other organs of respiration, as the diaphragm, the intercostal muscles, or the windpipe, or some of the neighboring viscera."

Pretty much that's all he offers us about our disease.  He then jumps right into his only remedy, his own balsamic medicines, the same medicines he recommends for consumptives.  He explains the first remedy to asthmatics is bleeding, yet after that he recommends balsamics to be provided by the inhaler he invented.

Here we must pay attention to his explanation:

"Well; but then we administer a quantity of saccharine, oily and mucilaginous medicine, in the form of an emulsion, intending, no doubt, thereby to sheathe and obtund the acrimony, which causes the irritation in the lungs.  The intention is certainly laudable; but it happens unfortunately that these balsamics go down, not into the lungs, but into the stomach, where they immediately go through such a change, as to carry but little of their balsamic qualities even into the intestines, where they are still farther mixed and adulterated, particularly by the addition of a certain quantity of bile, immediately on quitting the stomach."  (1, page 14)

He further explains that medicine can be taken by the mouth, pass through the stomach, gather access to the vessels of the body, and effect the heart, and even act as poisons in this way.  However, he notes the following:

"Now it must be remembered that the seat of the disorder which, by their healing medicines, we are endeavouring to cure is not in the blood vessels, but in the air vessels of the lungs; and that these air vessels have no communication with the arteries, except by means of tubes or pores so extremely small, as not to admit the red globules of the blood; consequently the constituent particles of our medicine must be smaller than these, otherwise no part of it can possibly be thus applied to the part injured." (1, page 15-16)

He therefore concludes that "the only possible way of applying medicine directly to the lungs, is through the windpipe."  (1, page 16)

Later he explains to the asthmatic:

"If... these balsamics, taken into the stomach, can do nothing toward the cure of consumption, how much less likely are they to relieve an asthmatic patient?  For if they could ever be applied immediately to the part affected, they possess no one virtue that might authorize such expectation." (1, page 34)

Here he makes an observation that was probably first made by ancient people, as even the ancient Egyptians, and Ancient Indians, observed that medicine to improve affections of the airway often works better when inhaled.  And that is exactly what Stern is prescribing here: the inhalation of his balsamic powders with an inhaler that he invented.

He writes that "when the cause of the asthma is spasmotic contraction of the lungs, or windpipe, which is very frequently the case, especially when the disease returns by fits, I then expect considerable advantage from the antispasmotic powders of this vapour; and when in a continuous difficulty of breathing, the cause of the disorder is an infarction of the lungs from viscid mucus, my hopes are then build on the attenuating power of the vapour exhibited in the manner I recommend. Let those who are capable of reasoning, judge whether my expectations are well founded." (1, page 34)

The medicine may be inhaled through the use of any teapot, although for consumption (or asthma) "a more copious application is necessary.  For this purpose I have contrived a simple machine, by means of which a much greater quantity of the balsamic effluvium is received into the lungs... It holds about a pint.  Half a pint of boiling water must be poured in, and the medicine immediately dropped into the water.  The head being then fixed upon it, the patient applies his mouth to the pipe, and thus draws in the steam with his breath, removing the pipe from his lips at every expiration.  The vessel is made of pewter.  Those who are acquainted with the nature of evaporation will not be at a loss to account for the conic form of the vessel."

Note he did not use the word 'inhaler.'  (3, page 54)  In reality his invention may be the first inhaler. However, perhaps because his ideas were rejected by the medical community, his inhaler never caught on.  He also didn't use the word inhaler. So perhaps for this reason it wasn't his, but Dr. Mudge's inhaler invented a decade later, that is often given credit as the first inhaler.  Yet for the first time, we will give Dr. Stern full credit here:  Dr. Phillip Stern invented the first marketable inhaler.

He also recommends inhaling the balsamic vapours using his contraption of which he does not refer to as an inhaler, as such a word will be used by one of his contemporaries.  (2) 

The medicine:  Dr. Sterns Balsamic Vapour or Dr. Sterns Balsamic Ether

Ingredients:  Dr. Sterns will not reveal his ingredients, although we might assume he enters into it some or all of the following, which are mentioned in his book:

•  Antiseptic powder
•  Ether
•  Balsams (of Gilead, Copaiba, Peru, Tolu, and Canada)
•  Dry Balsams (Benjoine, Storax, Labdanum, Myrrh, Mastich)
•  Terpentines
•  Antispasmotics
•  Opium

Research:  Dr. Sterns did a test using the vessel and his balsamic ether on himself, and it worked.

Indications:  Common colds, hoarseness, tuberculosis, asthma, etc.

Cost:  Six Schillings and sixpence per bottle

Where:  Various shops

Directions:  "I usually drop 30-40 drops into half a pint of boiling water immediately after it is taken from the fire, ordering the patient to hold his mouth over the vessel, so as to draw in with his breath as much as possible of the vapour, continuing the operation as long as the steam will rise.  I then order him to drink the water as soon as it is cold enough for that purpose: for, though I depend  entirely on the vapour for the cure of the lungs, yet, as of all the juices in the body may in some degree affected by the matter absorbed from the lungs, this balsamic water, received into the stomach, will be of some advantage." (1, page 24)

Or...

"30 or 40 drops to be dropped into a quart of boiling water, and the vessel to be placed near the bed of the patient, and to be repeated three or four times a day; or the water to be kept boiling over a lamp, in any part of the room, until it is entirely evaporated, if the disorder be of a very putrid nature, and especially in the small pox."  This technique may also be beneficial in sore throats "whether inflammatory or putrid."

Frequency:  The Stern's "Inhaler" may be used by adding half a pint of water, boiling it (2), "and by holding my head over a common pint vessel, keeping my mouth generally shut, that the steam might pass through my nose, and repeating the operation several times a day, for two or three days." (1, page 24)

When to use:  Use during an attack of asthma, although it is best to "prevent a disorder than to cure it, and as colds do no injury to the lungs, except in their remote effects, I thought it rational to suppose, if immediately after taking cold, I could dilute or obtund the acrimony of the humour that irritates and inflames the lungs, I should probably prevent the bad consequences of obstructed perspiration, at least as far as it concerned the lungs." (1, page 34)

References:

1. Stern, Phillip, "Medical advice to the consumptive and asthmatic people of England," 1870, London  (1st edition was 1767)
2. Sanders, Mark, "Dr. Stern's Inhaler," Inhalatorium.com,  http://inhalatorium.com/page133.html.  Mr. Sanders also provided us with permission to use the picture on this page.  Please check out the Inhalatorium to see for yourself the history of aerosolized therapy.  You may also check out a slideshow presentation by Mr. Sanders,    "The Innovators of Inhalation," http://www.ddl-conference.org.uk/files/DDL20presentations/19.Sanders.pdf
3. Smyth, Hugh D.C, Anthony J. Hickey, "Controlled Pulmonary Drug Delivery," 2100, Springer New York Dordrecht Heidelberg London

1985: Asthma Group Sessions

I don't remember group sessions as well as I wish I did.  Ric Donworth was my counselor, and he was also in charge of group.  Sessions were on Tuesday after school, so I imagine they were around 4 p.m.  All the adolescent patients admitted to 7-Goodman were required to attend, unless they were granted permission by a doctor for medical reasons, or if they were on a pass off the premises.  

I loved group.  I think some of the kids were like me and loved it, while probably half hated it.  I remember my room mate Eric usually sat slumped on the couch opposite wherever I sat, and he was sometimes defiant.  He was reticent to tell his story, and when he was the focus of the session Ric spent half the meetings trying to either coax Eric into talking, or allaying one of his concerns.  Yet for the most part he didn't speak much at these sessions unless it was to poke fun at someone, like me.  

I think there were a lot of purposes for the group session.  I think for the most part it was to make sure we were all getting along well, and to settle any conflicts.  I remember one of the conflicts revolved around me and, and I remember Willie gave me advice at one of the sessions.  He said, "Rick, I have good advice for you.  I think you get picked on because you are too girly.  I think you need to toughen up, and I mean that in a good way.  You can do simple things like... like the way you're sitting now."  He mocked how I was sitting.  "Your feel are aiming together, and that's how girls sit.  You need to slump back and spread your legs out.  You need to sit like a man.  Like this."  He showed me how men sit."  From that session on I always sat right.

Some of the sessions involved making rules for 7-Goodman.  I remember voting.  I don't remember what for.  I wish I did.  Yet I think most of the sessions involved conflict:  kid verse kid, kid verse nurse, kid verse doctor, kid verse parents, kid verse stress.  They also involved coping with asthma, getting to know other asthma kids, and that you're not alone.  Learning about the psychological consequences, and the fear of going to 2-may.  We talked about change.  Ric lead these sessions, and he always did so in a calm manner.  I always liked Ric.  

I remember sitting in the meetings for about two weeks before talking about myself.  I was the type of kid who needed to warm up to people before I got involved.  Finally at one session Ric told me it was time to share my story.  I told how I spent so much time in and out of emergency rooms.  Like many of the other kids in the room, I thought I was the only one.  Listening to the stories of the other kids made me realize things I experienced weren't experienced by just me.  

The two meetings I remember the most both involved Willie.  He was a black kid from Cincinnati. He was the kid who every time there was conflict said, "Later for it."  He was a break dancer, and twice the nurses held dancing competitions, and twice he won.  Once he came out of his room and stood in front of the nurses station in his long johns, and he wanted someone to take a picture.  I was the only one with a camera.  I still have the picture.  Willie was a good kid with a good heart.  

He was told he was going to go home.  He was afraid.  He told of alcoholic parents.  He said he'd have to live with his aunt, and he was afraid of her.  He said he wanted to stay here so he could be with his real friends.  He said, "I feel like I'm at home here. I really love it here.  I love all you guys." Really, before this session, Willie was always so calm and cool.  On this day he feared for his life.  

I met Willie at the tail end of his stay on 7-Goodman.  I never really had a chance to really know him.  But I did sort of during these meetings, and on 7-Goodman.  He did not want to go home.  And then he went home, and a week later Ric called me, Karl and Sean to his office so he could talk to us.  He said Willie was in the hospital again, and he wasn't doing well.  He told us about Willie, more than he probably should have.  He talked to us as though were pals and not patients.  And we were pals, because National Jewish wasn't a hospital, it was a home.  

So he called Willie and put him on the speaker phone.  We all talked to him as a group and then individually.  Then we said good-by.  It was the last time I ever talked to Willie.  I think thee was another similar session the next day, but because of a prior commitment I was unable to attend.  Willie was discharged to home, and we had a sigh of relief.  We knew his story, and we feared for his life.  Ric did too.  Yet a week later he was back in the hospital.  Ric told us that later that night we could call him.  Yet in school that day Shannon was crying.  I had no idea why she was crying. Mr. Rose tried to calm her down, but she left class.  

At about 1:00 that afternoon, or just after lunch on 7-Goodman, we returned to school only to have Mr. Rose tell us we all had to report to 7-Goodman right away.  A sudden silence stunned us all.  I remember feeling all shaky because I knew something bad had happened.  We all met on 7-Goodman in one of the back rooms on the south side of 7-Goodman.  We were all cramped in a room.  Ric was there.  He said, "There really is no good way to tell you this, so I'm just going to come out with it.  Willie passed away today."  

Yes, a cacophony of sighs and cries filled the room.  Ric told us we could have the rest of the day off.  The rest of the day was gloomy.  And at the next group session we talked about Willie.  There was a lot of speculating of why he died, and I don't think that there were any words that Ric could say to allay our minds.  Truly, there was nothing that could be said.  

So the most significant issue at these meetings was coping with life, and coping with asthma, and letting us know that we all share a common bond, and that we are not alone.  I can honestly say I am a better person today for having experienced 7-Goodman group sessions. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Withington explained that by... 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

He said each of these was...

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

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

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

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

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

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

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

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

He believed in the maxim:

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

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

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

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

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

These could also result in the following:

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

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

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

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

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

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

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

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

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

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

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

He stayed in A

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References:

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

   Aristotle (384–322 bc

   Aristotle (384–322 bc

   Aristotle (384–322 bc

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

1949-1969: The National Foundation for Asthmatic Children

One of the main reasons National Jewish Health was able to stay afloat through the years is that it recognized the changing health needs in America. While both National Jewish Hospital for Consumptives and Denver Sheltering Home for Jewish Children opened to provide opportunities for children and adults inflicted or affected by tuberculosis.

Between the 1940s and 1960s the number of tuberculosis patients declined, and the number of asthma patients increased. Plus there as a need for taking care of patients with other diseases, including emphysema, chronic bronchitis, cystic fibrosis, bronchiectasis, silicosis, sarcoidosis, and fungal infections (1)

Yet there was also an increased emphasis on research, hence the name change of the Sheltering home to Jewish National Home for Asthmatic Children at Denver in 1953, and in 1957 to Children's Asthma Research Institute & Hospital (CARIH). The hospital also performed research into immunity, and this was a major reason for the 1985 name change of National Jewish Hospital/ National Asthma Center to National Jewish Center for Immunology & Respiratory Medicine.

There was another institution in Tuscon, Ariona, that was similar to National Jewish. People with lung ailments flocked to Arizona due to its dry climate, which was perceived to better for adults and children with breathing difficulties. The National Foundation for Asthmatic Children (NFAC) was opened in Arizona in 1949. It was actually the first "diseased based organization to launch a national campaign on behalf of the asthmatic child. (2, page 115) During the 1950s National Jewish Home for Asthmatic Children started a similar educational campaign. (2, page 116)

Back then asthma was a little known disease, yet a massive advertising and public relations campaign by both National Jewish and NFAC increased awareness of the 2.5 million children in America with asthma. The campaigns increased awareness of the hospitals and research centers in both Denver and Tuscon. And the number of patients being referred to these hospitals increased. (2, page 116)

In 1973 CARIH changed its name to National Asthma Center, and admitted financial trouble by 1978, so it merged with National Jewish to create National Jewish Hospital/ National Asthma Center. This created the largest asthma hospital and research center in the world. Although there was an emphasis on patient care, the hospital continued to emphasize research.

While the school at NFAC closed in 1969, the hospital persisted. It was another option for children with hardluck asthma or other respiratory diseases. There was another such hospital in New York called Asthmatic Children's Foundation. In 1981 there were 15 similar residential treatment centers for asthmatics. (3)


In August of 2009 several former patients at NFAC met in Tuscon, Arizona to reminisce about their stay at the institution. The major emphasis back then about asthma was that medicine was used to treat acute symptoms, with included bronchospasm. Asthma was also a disease caused by a nervous disorder, or a suppressed cry for the mother. (4)

These kids were treated with a good course of education, exercise, and a good, healthy diet. They were also allowed to live a relatively normal life outside of that, by going on trips to town like normal kids, shopping, tours, amusement parks, parks, etc. They were also allowed to participate in games and other fun things kids do.

The kids "attend a boarding school for asthmatic children. These children can play out of doors year round and they become confident and competitive because they are competing with children on their own level," according A.B. Sieh, executive director for NFAC, in an article published in the Rotarian in August 1965. (5, page 51)

Boys and girls afflicted with bronchial asthma generally are admitted to the hospital for a one or two year stay, and this is at no charge, similar to the two asthma hospitals in Denver. The school the kids attend has a capacity of 72, and it's usually full (5, page 51)

Sieh notes that the "they come here pigeon chested with hollow eyes and sad faces... we have had children, who upon arrival, who could not walk up a single step without bringing on an asthma attack... the Arizona sun takes over and we have healthy looking children who can go home -- not cured, but rehabilitated to the point that they can cope with their asthma and live a normal life, attend public schools, and not be 'different.'

So while the main goal was to improve asthma, it wasn't like you were living in a hospital, at least not all the time. It allowed kids to get better, so they could go on to live normal lives.

References:

1. "Clinical History," NationalJewishHealth.org, http://www.nationaljewish.org/about/whynjh/history/clinical/clinical-history3/, accessed 11/7/12
2. Mitman, Gregg, "Breathing Space," 2007
3. Melvin, Tessa, "For 36 Children, Hope on Asthma," New York Times, September 26, 1982
4. Beal, Tom, "Tuscon asthmatic kids of reunite, view latest research," Arizona Daily Star, August 3, 2009
5. "These Rotarians: ABCs School," The Rotarian: An International Magazine, August, 1965