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Sunday, March 22, 2015

400 B.C. Tuberculosis is given a name

In the primitive world diseases were mainly described based on their symptoms. When the ancient Greeks observed that some patients appeared to be wasting away, they referred to their disease as phthisis, which means to consume or waste away.   Because it consumes, it would later called consumption.

While this is the disease we now refer to as tuberculosis, an ancient diagnosis of phthisis did not necessarily mean that the same patient would be diagnosed with tuberculosis today.  The truth is, while many patients diagnosed with phthisis might have had tuberculosis, they might have had any disease that can cause a person to seem to waste away, such as would be the case with many cancers.

So, as was the case with the term asthma, phthisis was essentially an umbrella, or rubric, term.  Phthisis referred to any condition that caused a person to appear to be wasting away, or to become cachectic.

The terms phthisis and consumption were used interchangeably by physicians referring to the disease.

Probably due to an early symptom of a dry cough, the ancient Greeks may frequently have misdiagnosed it as dry catarrh, or a common cold. This also resulted in catarrh, or inflammation, being suspected as the cause of the disease. (15, page 319, 320, 369)

In fact, Renae Laennec, in his 1919 book "Mediate Auscultation," said that from the time of the ancients, all the way to the late 18th century when many physicians became pathological anatomists and began performing autopsies in search of a better understanding of the diseases that plagued mankind, were tubercles discovered inside the lungs of those infected with the disease.  (15, page 319, 320, 369)

Laennec, therefore, would become the first person to use the term "tuberculosis" to describe the disease.  He used this term even though he most commonly used the term "phthisis pulmonalis."  (9)(13, page 29)

The ancient Greeks also used the term phymata to describe the tubercles observed in pulmonary tissue of humans, cattle, sheep and pigs infected with the pulmonary form of the disease, which became to be known as phthisis (learn how to pronounce it at (9)

Yet the ancient Greeks did not link tubercles with the disease phthisis.  In fact, the ancients, due to their lack of anatomical studies, did not understand what a tubercle was, and therefore it could have been any "accidental production," or abnormal growth, in the lungs.  This would include cysts, cancers, and tubercles. (15, pages 281-283)

Tubercles were also described by Claudius Galen, the greatest physician of the second century A.D. (16, page 285)

In his book "Of Internal Affections," Hippocrates describes the four types of phthisis: (14, page 281)
  1. Caused by increased phlegm (pituita) in the chest; recovery rare
  2. Caused by great fatigue; is less hazardous, but still very fatal
  3. Caused by spinal marrow being caused with blood
  4. Caused by drying of the spinal marrow and excess venery, and called dorsal phthisis. (14, page 281)
He offers a treatment for all of them, but for the third he recommends exercise, various roots and flowers, and a fumigation.  For the fourth he recommended large quantities of asses milk mixed with honey, or 14 pounds of cow or goat milk daily for 4-5 days. (14, page 281)

Interestingly, over 2,200 years later, Dr. Rene Laennec would still recommend assess milk as a treatment for the same disease.

However, the type of phthisis we are most concerned with is the first one, which more than likely affects the lungs, and probably the second type.

Because it present with obvious symptoms in life -- cough, fever, fatigue, hemoptysis, chest pain, no appetite, and wasting away, the disease was one of only two pulmonary diseases (pneumonia was the other) to be described by Hippocrates as a disease entity of it's own, with its own remedies. 

Hippocrates, therefore, was the first to describe phthisis as a medical condition, although, like pneumonia, he acknowledged it had been described by the ancients, meaning it had been known for quite some time.  He said it was "The greatest and most dangerous disease and one that proved fatal to the greatest number." (1, page 1)

He also considered it to be a hereditary as opposed to a contagious disease. A later Greek philosopher by the name of Aristotle considered it to be contagious, which opposed general consensus at the time. (10) 

By the year 1819, Rene Laennec said that most people still considered the disease to be contageous, although he was not confident this was the case.

In his book "On the Different Parts of Man," chapter 1 section 1, and then again later in the book, Hippocrates explains that disease resulted when the four humors of the body somehow became imbalanced.  More specifically, he believed phthisis, like asthma, was caused by an over abundance of phlegm being created by the brain. The excess phlegm, when it has nowhere else to go, travels to other organs, and in this case, the lungs.  (14, pages 226, 228, 235, 238)(also see 14, page 269)

Of course, Hippocrates explains, when the excess of phlem results in a fluxation (flowing) of phlegm to the lungs to cause phthisis and suppuration, or this secretions.  It also causes peripneumony (pneumonia and pleurisy).  When it flows to the nose it results in catahhr, or inflammation of the nasal passages (a cold or allergies).  When it flows to the spinal cord, this results in spinal medulla, dorsal phthisis, or what was later termed potts disease.  (14, page 228, 235)

He said that when excessive phlegm flows to both lungs, pneumonia occurs.  When the flow occurs in one lung, pleurisy occurs.  When the flow... carried to a single spot, and enters into the structure of the lungs, phthisis ensues; for when the humour reaches there slowly, bringing consequently but little moisture into them, it thickens, concretes, and drives in the bronchi; it excites cough by adhering to and filling the narrow cavities; rendering thereby an entrance to the air more difficult; from a defect of respiration, oppression of the breast ensues; a pricking sensation is felt in the lungs, which is not experience when the flow from the head to the part is more copious. If the fluxion (flow) becomes great, the whole body becomes surcharged (excessive), and the phthisis is changed to an empyema; and reversely, when the body becomes dry, the empyema (puss in a cavity of the body, particularly the pleural cavity, or the space between the lungs and its protective covering) passes from that state to phthisis. (14, page 238-239)
There are various causes for such an imbalance, one of which might corrupted foods that are consumed.  The corrupted food is mixed with "impure humours," thus resulting in a body that is "imperfectly nourished", resulting "soft parts that are surcharged (over burdened) with humours and receiving only aqueous matters, become engorged and tumid (inflamed or swollen).  (Definitions are from

The remedy for the disease, therefore, would be for something to occur, either naturally or by medical intervention, to re-create a balance of these humors.

In his book "On the Different Parts of Man, he said phthisis treated similarly to peripneumonia (pneumonia).  He said:
Peripneumony is to be treated in the same manner. In case of empyema, mild errhines, to excite a discharge from the nose, and thereby relieving the head, are to be employed, and such food as will loosen the bowels; if the disease is thereby arrested, and the humours diminish, we are then to promote expectoration, both by medicine and by appropriate food, by means of which coughing is excited. In order to effect this, the food should be of a fatty and saline quality, with wine of a rough character. Phthisical patients are treated in the same way, with the exception of giving less food at a time, and wine more diluted, so that the debilitated system may not be too greatly heated, and an afflux of humours thereby induced. (14, page 240)
For some forms of phthisis, particularly the type where "whitish sputa are expectorated.  This disease is cured by copious drinking and using the bath; expectorants are employed, and remedies to relieve the pain.  It is cured in seven days, and is not dangerous, nor is diet necessary." (14, page 242)

He did describe fumigations and an inhaler of sorts, but there is no evidence that he employed these for respiratory diseases.

The point of any intervention would be to re-establish the balance of the humours. If one is in excess, as would be the case with phthisis, where this would be the case with phlegm, something had to be done to reduce the amount of phlegm in the body.  Usually this could be accomplished by inducing a productive cough, vomiting, sweating, or bowel movement.

In "Predictions or prognostics," book II, Hippocrates said:
Of phthisis, advanced to the state of cough and suppuration, I shall refer to what I have already said of empyema. If likely to recover, the expectoration (spitting up phlegm) is easy, and should appear white, uniform in colour and in consistence, and free from pituita (thick nasal secretions). Humours (fluids) from the head should flow freely by the nose; fever should be absent, so that nourishment need not be interdicted (prohibited), and no thirst should attend. A daily evacuation of healthy fæces, in amount proportioned to the food taken, should take place; emaciation ought not to occur; the chest should be square and hairy; and the sternum, small and well covered with flesh, should not project. With such accompaniments, there is little danger; without them, death is not remote. In youth, when suppuration (discharge, pus) forms from congestion, or from previous ulceration, or any similar cause, or from a repetition of an abscess, a recovery is not to be looked for, unless there is a combination of nearly all the above favourable signs. Such persons commonly die in the autumn, as is usually the case in all other chronic affections. Women and girls, in whom phthisis occurs from suppressed menstruation, rarely escape. If it occasionally happens, besides the presence of the above symptoms, a perfect and regular return of the catamenia (menstrual condition) must follow, or there is no hope to be entertained. No less fatal in man, woman, and girls, is the suppuration succeeding to a profuse hæmoptysis (bloody sputum). It is by duly attending to all the symptoms mentioned, that a prediction can be given of health or death in phthisis accompanied with suppuration. Those who after hæmoptysis experience less pain in their back and breast, are most likely to recover; for their cough is less frequent, and though fever attends, it is accompanied with but trifling thirst. Nevertheless, the hemorrhage (bleeding) is often renewed, or an abscess is induced with a discharge of blood. When, with pains of the breast, emaciation (being abnormally thin or weak, or wasting away) slowly advances, with cough, and difficult breathing, but unaccompanied by fever or discharge of pus, we must inquire if something of a compact nature and of an offensive odour is not discharged by coughing. (14, page 130, page )
Isocrates (460-338 B.C.) is often considered as the greatest rhetoricians' in Ancient Greece.  His intent was to improve the speech and writings of individuals by instilling virtues.  He was born in 436 BC, seven  years before Plato was born. Like Aristotle, Isocrates also mentioned that phthisis was contagious.  (1)

Daniels said the disease must have subsided in Egypt by the time of ancient Greece, and the disease was not mentioned much in ancient Roman literature, causing historians to surmise the disease was not very common.

However, the Greco-Roman physician Galen did write about the diseaseand he believed it was an "ulceration of the lungs, thorax or throat, accompanied by a cough, fever, and consumption of the body by pus."

He considered the treatment for the malady to be living at high altitudes, like the top of a mountain. This remedy would become a fad from the mid 19th century to the mid 20th century, when the disease would finally be controlled by modern civilization.

  1. Norris, Charles Camblos, "Gynecological and Obstetrical Tuberculosis," 1921, New York, London
  2. Koehler, Christopher W., "Consumption, the great killer,"
  3. "History of TB," New Jersey Medical School, Global Tuberculosis Institute,
  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
  13. Daniel, Thomas M., "Pioneers in Medicine and their impact on Tuberculosis," 2000, University of Rochester Press
  14. Hippocrates, Claudius Galen, writers,  John Redman Coxe, translator, "Hippocrates, the Writings of Hippocrates and Galen," 1846,, accessed 7/6/14, also see the book online at Google books, Philadelphia, Lindsay and Blakiston
  15. Laennec, Rene, "Mediate Auscultation," translated by John Forbes, Notes by professor Andral, 4th edition, 1838, New York, Samuel S. and William Wood
  16. Laennec, Rene, ibid, from the notes by Dr. M. Andral
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