400-1743: The first use of the term influenza

In the ancient world all diseases were attributed to the wrath of the "diety." If a Pandemic ravaged a village, town or nation, it was attributed to an angry god or spirit.  Both the ancient Greek poet Homer (800-701) and Hippocrates (460-370) described pandemics during their lifetimes.  It's probable some of these were attributed to the influenza virus. 

Homer describes how Zeus used his thunderbolt to "punish impiety," and "for vengeance for an insult offered to his priest, the shafts of the Sun-god carried sickness into the Argive camp, destroying first the dogs and mules, and then thousands of warriors," writes Arthur Hopkirk, in his 1914 book "Influenza."  (1, page vii and viii)

In reality these warriors may have died of a pandemic caused by a virus or bacteria, such as influenza.  Although the ancients had no clue about the internal workings of the human body, nor about invisible invaders of the human body.  It was easier for them to believe in fake gods and attribute them when bad things like plagues happened.

"On mules and dogs th' infection first began;

And last, the vengeful arrows fix'd in man."

Those described as having sweats and chills (signs of a fever) were the most likely to succumb to the disease.  In man's desire to help his fellow man, the following were the remedies tried (1, page 15-16):

• Purging
• Venesection
• Bleeding by the ranal vein
• Emetics

And sometimes the remedy wreaked more havoc than the plague.  If ruthless venesection was performed, this in and of itself could have been the killer.  Yet the plague was blamed nonetheless.

The plague struck again and again.  In 412 B.C. the following was written regarding a plague in Rome (1, page 16):

“A plague, however, which broke out at that time and gave more alarm than it proved destructive, diverted the people’s attention from the forum and political disputes to look after their families and take care of their health. The city was all over oppressed with sickness, though no great mortality ensued.”

It struck again (or so historians think) in (1, page 20-26)...

• 827 A.D. in France and Germany
• 876 in Italy
• 889 in Germany
• 927 in France and Germany
• 996-97 in England
• 1173 in Germany and Italy (it was called "a dense fog" in Italy, first authentic outbreak)
• 1239
• 1311
• 1323 in Italy and France
• 1327-28
• 1357
• 1287 in France and Germany
• 1403 in Paris, France
• 1404
• 1410-11 in France
• 1413-14 in France
• 1427 in France caused a "Poisonous air."
• 1438
• 1482
• 1505
• 1510

The following quote comes from 1323 (3):  

In the year, 1323, and in the month of August, there was a pestilential wind, which caused nearly all the inhabitants of Florence to fall sick of cold and fever, and the same thing took place throughout almost of whole of Italy.

And the following from 1327 (3):

In the said year and month, there was throughout the whole of Italy an infection fever caused by cold; but few people died of it.

Regarding the 1387 outbreak, the following was written (4):

There came a general pestilence in the whole country, with cough and influenza, so that hardly one among ten remained healthy. 

Regarding the 1427 outbreak, an anonymous chronicler from St. Albans wrote (1, page 25-6):

In the beginning of October, a certain rheumy infirmity which is called 'mure' invaded the whole people, and so infected the aged along with the younger, that it conducted a great number to the grave. 

The remedy for the 1387 pandemic, which took few lives, was "decoctions of chamomile and coriander berries, sweetened with syrup and poppies; clymasta; diaphoretics; and low diet." (1, page 23)  This would have been a more pleasant remedy compared to what the ancient Greeks treated the symptoms.  

Many of the deaths that resulted occurred on the fifth or sixth day, and Hippocrates notes that death usually occurred on the seventh day.  Later, in the first century A.D., Galen agreed with Hippocrates that death usually occurred on the seventh day.  (1, page 17)

At some point in our history, sometime in the ancient world, the concept that little creatures in the air may be responsible for spreading some diseases was postulated, although who postulated this theory, and when, remains a mystery.

Hopkirk says the first to write of this concept may have been the Greek "polyhistorian" Varro (117-36 B.C.), who wrote the following:

It is to be observed that wherever there are marshy districts certain most minute animals will grow, which cannot be discerned by the eye; but, carried by the air, reach the body through the mouth and nostrils, causing serious disease." (1, page x)

Varro was referring to the malaria plague in "Corfu when Pompey was there with an army and fleet."  Although the same concept may be applied to other contagious diseases, such as influenza.  Varro recommended the following to prevent the spread of the disease malaria: (1, page x)

• Isolation
• Ventilation
• Destruction of insanitary dwellings
• Etc.

Influenza is known to cause much grief for those afflicted with it, although it causes only a few deaths.  Usually those who die from it are over the age of 65 or have some chronic underlying medical condition that is complicated by influenza.

Prior to the 16th century influenza was referred to by various names, depending on the geographic region of the person describing it.  Sometimes it was simply referred to as a pest, pestilence, or plague.  Historians determine if the "plague" was influenza by descriptions of the symptoms, a high morbidity, yet low mortality rate.  If many deaths resulted, chances are that particular plague was not influenza. (1, page 4-5)

The term influenza may actually have come from a misinterpretation of the Italian word influence.  The idea here is that around 1357 people believed the position of the stars "influenced" outbreaks of the disease.  Although how this term superseded all the other terms and made it's way into medical nomenclature remains a mystery.  (1, page 6)(2, page 31)

The following are just a few other names used to describe various pandemics or endemics most historians figure were influenza (1, pages 8-9):

1. Burzelen:  1307 in Germany (meaning to stumble?)
2. Le tac or le horion:  1411 in France
3. Tonawasches Fieber:  1414 in Germany (Because occurred in Danube district)
4. Coqueluche: 1414 in France (Caused oppressive pain in the head)(Victims wore cap on head)
5. Ladendo:  1427 in France
6. Schafkrankheit or Schafhusten:  1580 in Germany (Sheep's disease, cough)
7. Galanteriekrankheit or Modefieber: 1709 in Germany (Galant malady, fashionable fever)
8. Le Grippe:  1743 in France (from "agripper," meaning to sieze quickly and cause sore throat
9. Petite poste or petite courrier:  1762 in France
10. Zamporina:  Brazil in 1780
11. La Coquette:  France 1780-81
12. Russische Krankheit (lightning catarrh):  1782 in Germany (due to its sudden onset)
13. Corcunda (hunchback disease):  Brazil in 1816.  Violent cough made you hunch your back
14. Polka Fever:  1846-7 in Brazil

In Great Britain during the 14th and 15th centuries, common names were faucht and slaodan.  Creatan was a word derived from creat (chest), and was another common name.  In 1562 it was called "the newe acquayntance.  In 1580 "the gentle correction."  It was also referred to as "the jolly rant," "the new delight," "the Dunkirk rant," and "the knock-me-down fever." (1, page 9)

An outbreak in Britain in 1485 was described as "English Sweat." It was so back that "King Henry VII had to postpone his coronation," according to Evelyn Kelly and Claire Wilson in their 2011 book "Investigating Influenza and Bird Flu."  "The disease was treated with tobacco juice, lime juice, and bloodletting." (2, page 32)

Finally, in 1743, the term influenza was used to describe influenza.  No one knows why, but this is the term that stuck, and has since made it's way to medical nomenclature.  The only exception was in Germany, where the Grippe was the term commonly used as of 1743.  

While the names varied through early history, the "grip" the disease held on it's victims were similar:

• Catarrh:  Inflammation of the respiratory tract (nasal congestion)
• Fever:  Usually over 100 degrees
• Chills:  Associated with the fever
• Headache:
• Body or muscle aches: Especially of the back, arms and legs
• Dry cough: Helps spread the disease from one victim to the next
• Fatigue and weakness:  General feeling of tiredness
• Suspended Business: Many stopped working to take care of their families

It's generally the commonality of symptoms described, the high rate of morbidity, and low mortality, that has allowed historians to feel confidence these epidemics and pandemics were probably influenza.  

References:

1. Hopkirk, Arthur F., "Influenza: It's History, Nature, Cause and Treatment," 1914, New York, Charles Scribner and Sons
2. Kelly, Evelyn B., PhD and Claire Wilson, "Investigating influenza and Bird Flu: Real facts and real lives," 2011, Enslow Publishers, U.S., Chapter 2, "The History of Influenza," pages 29-47
3. Hopkirk, op cit,Gluge, "in the course of his argument, quotes the following passages from Buoninsegni’s Istoria Fiorentina, Florence, 1580." The passages are recorded on page 21 of Hopkirk's book.  
4. Hopkirk, op cit, from Jakob von Konigshoven Stassburg Chronicles, of 1387, as recorded by Hopkirk on page 22 of his book

1750-1850: Tuberculosis wreaks havoc

The industrial revolution swept across the modern from 1750-1850. New inventions improved agriculture, manufacturing, mining, transportation and technology, and this had a stunning effect on culture and economies.  The world was forever changed for the better, or so people suspected.

Yet while culture and economies improved, a vicious killer spread across this modern world.  No one knew what it was. No one knew where it came from.  No one knew what to do about it.  The killer was generally referred to as consumption, and if you got it you were probably doomed. 

Yet since people were ignorant about what it was, and what caused it, and how it was contacted, they didn't know that by getting together in poorly ventilated areas of mills and factories that they were breathing the contaminated air that was exhaled by people who had the disease.  They didn't know that the bacteria was transported through the air and was inhaled.  

They didn't know the disease was spread by sharing hanker chiefs, and by touching contaminated people.  They didn't know that the disease was prevalent before the industrial revolution, but the disease was more of a random disease that occurred here and there by chance.  Yet with the beginning of the revolution, people gathered in small, poorly ventilated areas.  People moved to cities, right into the grasp of the killer.  They did this because they wanted to create a better life for themselves and their children, and they did this not knowing they were living with a beast.  

There were a variety of names for it.  It was called scrofula (swollen lymph nodes), Pott's disease (TB of the bone, spine), the Great White plague (17th century Europe), consumption or phthisis (TB of the lung),  lupis vulgaris (TB of the skin), Mesenteric disease (TB from non-pasteurized milk), white swelling (TB of bone), and King's Evil (TB of of lymph glands). Or sometimes it's simplty referred to as "captain of the ship of death." (9)  We refer to it as tuberculosis.  

A plague swept through Europe in the 16th century, and during this time what Hippocrates referred to as phthsis was referred to as the Great White Plague.  Yet it was usually described by scientists and physicians as either phthsis or consumption and sometimes even scrofula.

During the next 200 years thousands would be killed.  Little was known about it other than it's symptoms.  Usually, a patient was diagnosed by a physician only after the patient noticed he was coughing up blood.  By this time the disease was near its later stages, and prognosis was grim.

  Franciscus dele Bo Sylvius published a book in 1679 called the Opera Medica in which he made the association between nodules in the lungs with phthisis.  Perhaps as a result, in the 17th and 18th centuries there were many references to the disease being contagious, and many warnings about those infected with it.  (3)  Yet for the most part physicians thought it was hereditary, as Hippocrates thought.

Giovanni Baptista Morgagni, an Italian anatomist who lived 1682-1771, wrote quite a bit about medicine in his later years.  He warned that the condition might be an infection and he warned against doing autopsies on anyone infected with it. (1, page 2)

TB was called white plague from 18th-19th centuries

Right around the turn of the 17th century a health edict in the Republic of Lucca in Italy warned: "Henceforth, human health should no longer be endangered by objects remaining after the death of a consumptive. The names of the deceased should be reported to the authorities, and measures taken for disinfection.”(2)

English Physician Benjamin Martin published a book in 1720 called "A New Theory of Consumption."  He wrote that the disease was caused by "wonderfully minute little creatures."  He believed these "creatures" enter the body and cause the symptoms.

Likewise, Martin believed that those in close proximity to the patient, particularly those talking to the person, should be careful.  He wrote:

"It may be therefore very likely that by an habitual lying in the same bed with a consumptive patient, constantly eating and drinking with him, or by very frequently conversing so nearly as to draw in part of the breath he emits from the lungs, a consumption may be caught by a sound person...I imagine that slightly conversing with consumptive patients is seldom or never sufficient to catch the disease."

In 1793 Dr. Matthew Ballie published a book "Morbid Anatomy of Some of the Most Important Parts of the Human Body." (?check year and book)  He provided a description of the lungs and many lung diseases.  He wrote about consumption, and was among the first to note nodules in other organs other than the lungs.

In 1689 Richard Morton (1637-1698) used the term "tubercle" to describe lesions he saw in organs of those who died of consumption.

Rene Laennec was born in 1787 and contacted tuberculosis as a young adult.  He became rapt in studying this disease during the course of his career as a physician.  He is best known for his invention of the stethoscope.  He was also the first to master its use.  He was also the first to see tubercles in lung tissue of those patients?

In 18? he published "A Treatise on Diseases of the Chest, and of Mediate Auscultation."  He
described how to use the stethoscope in assessing and diagnosing patients.  He also discussed the pathology of many disease processes, including what was used it to describe symptoms during various stages of the condition.

Laennec met his demise by the grips of tuberculosis in 1826 at the young age of 45.

Samuel George Morton  (1637-1698) was a pupil of Laennec.  In 1834 he published his own book titled "Pulmonary Consumption."  This would be the first book on the subject published in the United States. (4, page 10).  He recommended that the age old practice of bleeding patients who are coughing up blood was a "plan that has hurried thousands of patients to their graves by destroying the last remains of strength."

However, if the patient was of good strengh with a good pulse, he recommended "ten or twelve ounces of blood, taken rapidly from a large oriface, may divert the current of the circulation and relieve the pulmonary congestion."  (5, page 120).

This would work because the condition resulted in ulcers which dry and the blood becomes congested around these regions causing the ulcers to burst, and this is why these patients spit up blood.  He beleived bleeding prior to this happening would help prevent the congestion.

Other remedies may may also help "promote absorption of the congested blood" include:

• Spirits of turpentine
• Elixer of vitriole
• Common salt
• Opium
• Sugar of lead
• Rest
• Diet of gum water and farinaceous food

He likewise agreed with a Dr. Beddoes who recommended a ride in the fresh air as treatment.  Morton quotes Beddoes:

 "In haemoptysis and pulmonary hemorrhages, I never observed any bad consequence from traveling in a carriage:  on the contrary, I have known these discharges to stop on a journey, though previously they had, for many days, occurred at least once in twenty-four hours."

Johan Lukas Schönlein (1793-1864) wrote relatively little during his life.  He wrote a doctoral thesis and two papers of 1 and 3 pages respectively, although that was it. Still, despite his lack of enthusiasm for writing, it was Schönlein who introduced the terms hemophilia and tuberculosis (1839). The word "tuberculosis" was derived from "tubercle", a word introduced by Morton in 1689 to describe the characteristic lesions of consumption.

The mid 19th century was a time when many scientists and doctors were experimenting with microbes.  In 1843 Dr. Klencke became the first to cause an animal to develop the condition by innoculating a rabit with "portions of miliary and infiltrating tubercules from a man.  Klencke, after accomplilshing this result, did not continue his investigations, and they were consequently soon forgotten."  (6)

Despite all the research that had been done prior to 1865, many physians believed that each case of tuberculosis "rose spontansously in predisposed people."  (2)  Yet it was in 1865 that a French military physician named Jean Antionne Villemin proved that tuberculosis was caused by an infecting organism.

He innoculated cattle with both human tuberculosis and bovine tuberculosis. (6)  He thus proved that two diseases were of similar origin, and he proved that the disease could be transferred form a human to cattle and from cattle to rabbits.  (2)

Regardless of Villemin's work the idea that tuberculosis was a spontaneous condition was ingrained in the minds of many, and they performed many experiments trying to prove Villemin wrong.  Yet in the end Villemin's ideas won out.  Although it took a few years.

Robert Koch (1843-1910) was the next to perform many experiments on tissue from tuberculosis victims to see if he could learn more about it and come up with a cure.  He invented a staining method that allowed him to see the tubercle bacillus.  And, through "artificial cultivation," he was able to grow the bacillus.  He then proceeded to reproduce the characteristics of tuberculosis in animals.  He also identified different forms of the disease in various animals.

Today paleopathologists (scientists who study ancient diseases) are unable to identify tuberculosis by finding the bacteria because they "disappear" shortly after the victim dies.  (8)  Yet some types of the disease effect bones and joints leaving scars that can be identified.

References:

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

Photos:

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

Further reading:

• Essentials of tuberculosisi in children
• Johnson, H.A., "Consumption in the Northwestern States," The Chicago Medical Journal and Examiner, Volume 37, William M. Syford, et al, editors, 1878, pages 133-143

1976: What causes asthma?

So it's 1976 and you're an asthma doctor.  You look into your medical books and magazines to get an update on the latest asthma wisdom.  When you were in medical school in the 1950s you were taught asthma was a disease of bronchospasm that mainly occurred when the asthmatic was anxious or stressed.  You want to know if things have changed.

Ever since the 1850s doctors suspected the mother as a major source of asthma.  In 1976 a report in the Archives of General Psychology noted that most psychologists "generally agree on the mother as one primary cause of childhood asthma.  'Something in the mother's personality sets off a child's dark, hidden fears and anxieties,' the theory goes.  'This in turn produces allergic reaction in the child which constrict the bronchial tubes and make breathing difficult or even painful."  (1, page 125)

Most psychologists agree that the mother is a source of stress for the asthmatic.  When the mother scolds the child this induces an inner anxiety.  Of course mothers may not understand that an asthmatic child may have psychological issues of his own just because he is asthmatic, such as:

• Kids picking on him because he is wheezing, sniffling and sneezing
• Kids picking on him because he is perceived as the wimp because he can't play sports 
• Not being able to do things with his dad, such as hunting camp, hunting, stacking wood
• Not being able to play with his siblings in the dusty basement, fort, outdoors.
• Not being able to play outdoors in cold weather
• Not being able to play outdoors when chimney smoke fills the air
• Humidity:  Yes, that humidifier your mom and grandma used can make asthma worse because it makes the air thicker, and creates a breeding ground for germs

All of this is true, and all of this causes anxiety.  Yet these in and of themselves are symptoms or consequences of asthma, not the cause.  Yes, they can make asthma work, but they do not cause asthma.  Yet, still, asthma experts in the 1970s and 1980s don't quite understand this.  They continue to place a major emphasis on the the theory "it's all in your head," as opposed to looking elsewhere for causes.  

However, and thankfully, the psychological theory of asthma started to fade in the 1970s.  More and more studies seem to disprove it.  Many doctors and psychologists start to doubt this theory, and they start to postulate new ones, such as (1, page 124-127):

• Air pollution causes it.  Studies start to confirm this
• Eczema causes it.  About 50% of kids with eczema end up with asthma 
• Food causes it.  Many kids are showing signs of milk and chocolate allergies
• Infections cause it:  Many kids with colds end up with asthma symptoms
• Emotion causes it:  Yes, it can still trigger an attack
• Family incompatibility:  Yes, stress induced from parents can cause it  Mom's who refuse to get rid of dogs.  Moms who refuse to get rid of indoor plants.  Parent's who refuse to become educated about this disease, and get irritated when their child is different than other kids
• Climate changes:  Living near allergens, hay fields, grass fields

Yes, the asthma experts start to look in other areas, and this is a good thing.  It pretty much sets up the next stage in the evolution of asthma, which takes place in the late 1990s with the initiation of asthma guidelines.

Another idea that still abounds is the removal of the asthmatic from the climate.  If the child lives around a hay field, it may be best to move to a region of the United States where there are no hay fields or other such allergens.  Many are still taking their asthmatics to places of higher altitudes and drier air, such as Denver and Phoenix.

Many asthmatics quit their jobs, or quit school, and moved away from their family and friends seeking a place where their asthma or allergies was improved.  Some left permanently, and others left temporarily. Some were removed from their homes and admitted into asthma institutions like National Jewish Hospital/ National Asthma Center in Denver, Colorado. 

The theory that asthma is all in your head starts to fade in the 1950s, and the idea that asthma is caused by other things, such as pollution, also start up at this time.  But convincing a dogmatic medical community often takes time.  Yet once new causes are understood, this can often lead to better treatment, and a better life for the asthmatic.

New ideas have to be taught to a new generation of medical students, and the older doctors either have to accept change, admit they were taught fallacies, or we just have to wait for them to retire.  New ideas like the ones above slowly grew in the medical community by the process of assimilation. 

References:

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

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