460-370 B.C.: What did Hippocrates think about asthma?

Hippocrates is given credit as the author of the Corpus,
and therefore as the father of medicine.  The truth is,
however, that the figure in the bust here is probably
 a composite of what a typical physician would look like
around 400 B.C. The name Hippocrates has become
synonymous with the transformation of medicine that
occurred during this era of history.

As we peruse ancient writings we find many references to asthma, or at least asthma-like symptoms. The ancient Egyptians, Greeks, Chinese and even Japanese all recorded asthma-like events and the remedies to go along with them.  Yet it was Hippocrates,  particularly in his Corpus Hippocraticum, who made asthma a household name.

Please note here that Hippocrates was an actual physician, although his name is generally attributed to the medical wisdom of this era.  So as historians contribute the birth of medicine to Hippocrates, they are actually referring to the accumulated wisdom of Hippocrates and all of his immediate ancestors, fellow physicians, and immediate followers.

As far as we know, the first known person to use the term "asthma" was Homer in his epic poem the Iliad, which was written about 800 B.C. Homer used it to denote gasping or air hunger that occurred after physical exertion or during the process of dying.

As was typical of the era of philosophers in ancient Greece, Hippocrates had questions and he yearned for answers.  He wanted to know about all diseases, their causes and cures.  With limited ability to inspect the insides of the human body, his anatomical wisdom was limited.

He had no means of associating symptom seen outside the body with changes that occurred inside.  He therefore was forced to use reason to answer his questions about diseases such as epilepsy, dropsy, colds, catarrh, and asthma.  These answers were called theories.  They may seem quite spurious to the modern reader, although to the ancient Greeks they were quite logical.

So when Plato, and then Hippocrates, used the term asthma, they were pretty much denoting a symptom rather than a disease.  Plato used the term to denote short, gasping breaths by those wounded in battle or those who were exhausted after running from an enemy. Hippocrates used it in a similar way, although his definition was a bit more refined.

For example, Hippocrates defined the various forms of shortness of breath:

1. Dyspnea: Shortness of breath
2. Asthma (asthmata): Severe shortness of breath
3. Orthopnea: So short of breath you have to sit up to breathe (a bad sign)
4. Tachypnea: Rapid respiratory rate

In this way, he was the first to define asthma as a medical term. Since he didn't understand anatomy, asthma became a rubric term, an umbrella term, for severe breathing difficulty.  So from this point on, if you were short of breath, you had asthma, regardless of the natural cause.

To Hippocrates, then, like headache and fever, asthma was merely a symptom.

While this was a very vague definition, it was a start.  Later, as new wisdom was learned, the definition evolved.  Diseases that did not fit under the newer definition were extricated from under the umbrella term asthma to become disease entities of their own.

The first two examples were probably peripneumonia and phthisis, two diseases we now refer to as pneumonia and tuberculosis (consumption).  Diseases extricated after the death of Hippocrates were scoliosis, cardiac asthma (heart failure), kidney asthma (kidney failure), croup, chronic bronchitis, emphysema, and chest deformities.

It's interesting to note that chest deformities, such as diseases that caused curvature of the spine (scoliosis), were also considered asthma. This was true because such deformities resulted in less space in the chest for the lungs, leading to dyspnea. Hippocrates mentioned this in one of his Aphorisms:

Such persons as become hump-backed from asthma or cough before puberty, die. (17, page 141

Hippocrates also observed redness and inflammation inside the nose, mouth and eyes of some patients, and he referred to this as catarrh.  By this he was observing what modern physicians might diagnose as the common cold, bronchitis, or allergies.

He wrote a treaties "Of Epilepsy."  Prior to Hippocrates, epilepsy was referred to as the sacred disease because it originated from the anger of the gods, most likely Cybele, Neptune, Proserpine, Apollo, Mars, and Hecate.  Hippocrates tried to explain that epilepsy was "nothing more sacred or divine than an other." (11, pages 201-203)

Hippocrates believed that instead of being a divine disease, epilepsy had a natural cause, which started by an increase of phlegm in the brain that ultimately made its way to the veins and impeded flow of pneuma to the brain. He said:

This malady, then, affects phlegmatic people, but not bilious. It begins to be formed while the foetus is still in utero. For the brain, like the other organs, is depurated and grows before birth. If, then, in this purgation it be properly and moderately depurated, and neither more nor less than what is proper be secreted from it, the head is thus in the most healthy condition. If the secretion (melting) from the whole brain be greater than natural, the person, when he grows up, will have his head diseased, and full of noises, and will neither be able to endure the sun nor cold. (14)

Hippocrates, like Greek physicians before him, believed asthma was epilepsy of the lungs.  He believed that air (with pneuma) was inhaled and flowed through the body by means of the veins.  It flowed to the heart and brain and other organs in order to keep them functioning.

Hippocrates said:

By these veins we draw in much breath, since they are the spiracles of our bodies inhaling air to themselves and distributing it to the rest of the body, and to the smaller veins, and they and afterwards exhale it. For the breath cannot be stationary, but it passes upward and downward, for if stopped and intercepted, the part where it is stopped becomes powerless. In proof of this, when, in sitting or lying, the small veins are compressed, so that the breath from the larger vein does not pass into them, the part is immediately seized with numbness; and it is so likewise with regard to the other veins. (19)

He also believed that the humor phlegm was made in the brain.  When it was in excess it could flow to the heart and lungs, thus causing asthma. (9, page 61-62) (10, pages 14-15)

He said:

But should the defluxion (flow of humors) make its way to the heart, the person is seized with palpitation and asthma, the chest becomes diseased, and some also have curvature of the spine. For when a defluxion of cold phlegm takes place on the lungs and heart, the blood is chilled, and the veins, being violently chilled, palpitate in the lungs and heart, and the heart palpitates, so that from this necessity asthma and orthopnoea supervene. For it does not receive the spirits as much breath as he needs until the defluxion of phlegm be mastered, and being heated is distributed to the veins, then it ceases from its palpitation and difficulty of breathing, and this takes place as soon as it obtains an abundant supply; and this will be more slowly, provided the defluxion be more abundant, or if it be less, more quickly. And if the defluxions be more condensed, the epileptic attacks will be more frequent, but otherwise if it be rarer. Such are the symptoms when the defluxion is upon the lungs and heart; but if it be upon the bowels, the person is attacked with diarrhoea.  (14)

Mervyn J. Eadie and Peter F. Bladin, when writing about the sacred disease of Hippocrates, explained the thinking of Hippocrates regarding the cause of epilepsy and asthma.  They said:

He (Hippcrates or the Hippocratic writers) considered the disorder (epilepsy) in the following way:  during normal prenatal development the brain underwent a process of purification as it grew in the womb.  If this purification process did not occur, the sufferer was likely to grow up with a diseased head.  Purification of the brain might still occur after birth.  If so, phlegm would then be secreted into the upper respiratory tract or lost from the body in discharged from ulcers.  If such purification, which should have got rid of phlegm from the brain, did not occur at some state, the sufferer would be prone to experience epileptic seizures. When a 'defluction' of the retained phlegm from the brain occurred, the phlegm might go to the heart and chest to cause palpations, asthma, chest disorders and possibly spinal deformity. If it went to the abdoment it caused diarrhoea.  (18, page 94)

If the cold phlegm was not able to make it into the lungs or abdomen, it entered the veins where it obstructed the flow of pneuma.  When the pneuma was obstructed this could result in seizures, but it could also result in "interruption of inspiration."  (18, page 94)

When the pneuma was unable to make it back to the brain this caused "interruption of speech and intellectual functions, and loss of power in the hands.  The palpating veins affected the lungs to cause froth to emerge from the mouth.  The violent suffocation might cause involuntary defaecation, as the liver and stomach ascended to the diaphragm and the mouth of the stomach closed. (18, page 94)

So asthma was basically a symptom of a greater problem which ultimately originated from too much phlegm being created by the brain.

In his "Airs, Waters, and Places," he said:

...infants are subject to attacks of convulsions and asthma, which they consider to be connected with infancy, and hold to be a sacred disease (epilepsy). (14)

Hippocrates said:

Infants are subject to attacks of convulsions and asthma, which they consider to be connected with infancy, and hold to be a sacred disease (epilepsy) (13, pages 9, 11)

From these two passages many experts speculate Hippocrates observed that epilepsy and asthma were common in infants.

He also alluded to asthma as being "convulsive" or spasmotic in nature.  In other words, he alluded to what would later be referred to as the spasmotic theory of asthma, or that asthma was caused by "convulsions" or spasms in the lungs.

Paul Ryan, in his 1793 book "Observations on the history and cure of asthma," said:

It appears extremely probable that Hippocrates, in placing asthma... in contradistinction with pleurisy and peripneumony (pneumonia), must have had in view the spasmotic kind... he says that old men are very subject to difficult breathing, cough, and catarrhs and defluxion on the lungs. (9, pages 59-60)

After Hippocrates wrote about the disease as spasmotic in nature, later physicians suspected asthma was a nervous disorder.  It wouldn't be until the early 19th century that it was proved that Hippocrates was right all along, at least about asthma being spasmotic in nature.

Although others speculate that since asthma was associated with epilepsy, and that it was caused by defluxion of humors from the brain, that it was indeed a mental illness, or a nervous disorder.

Bernardino Ramazzini said Hippocrates was probably the first to describe asthma as a hazard of certain occupations.  Although the idea was scrapped until Ramazzini picked it up in the 17th century, and then scrapped again until the middle of the 20th century.

Hippocrates also accurately described asthma as a disease inherited along the family line, and while this was supported by an occasional physician along the historical timeline,  it wasn't proved until hundreds of years after the fall of Greece and Rome.

Despite his possible association of asthma with spasms in the lungs, he did not, as a general rule, associate diseases with specific organs.  This would be the accomplishment of a great physicians born into the 2nd century B.C. named Galen.

Hippocrates speculated that diseases were caused by certain changes in the winds, changes in temperature, or by the ingestion of certain foods. These caused a disunity within the body of the four qualities and humors, thus causing disease.

For example, some aphorisms describe asthma as occurring commonly in the middle ages, when the body functions start to slow down and cool, and in the fall season, when the temperatures start to cool.

Image of Hippocrates (12, title page)

Hippocrates said:

In autumn many maladies which occur in summer prevail, besides quartan and erratic fevers, affections of the spleen, dropsy, consumption, strangury, dysentery, sciatica, quinsey, asthma, volvulus, epilepsy, mania, and melancholy. (12, page 59)

He added:

To persons somewhat older, affections of the tonsils, incurvation of the spine at the vertebra next the occiput, asthma, calculus, round worms, ascarides, acrochordon, satyriasmus, struma, and other tubercles (phymata) but es- pecially the aforesaid. (16, page 134)

Ryan added:

...that the asthma mentioned by him was of the spasmotic kind, and that he considered cold and moisture its principle causes.  At least it must be allowed that this was his opinion with regard to the disorder in children. (10, page 62)

In review, he believed the following was true of asthma:

• It was related to the epileptic resonse
• It was hereditary
• It was convulsive or spasmotic in nature
• It was caused by an abundance of cold phlegm flowing from brain to lungs
• It was common in infants
• It was common in the elderly
• It was caused by changes in seasons, such as from summer to fall (cooler air)
• It was caused by some occupations
• It is common in phlegmatic persons

It is generally believed that Hippocrates redefined the mode of assessing and diagnosing patients.  He made a thorough examination of the patient and his surroundings.  He assessed the patient's breathing both by observation with his eyes and with his ears.

He listened to his patient's breathing, took his respiratory rate, felt for a pulse, felt his skin for fever, observed perspiration and sweating, inspected his urine, inspected his sputum, among other things.

He may even have shook his patients in order to hear phlegm in the chest, a procedure called succussion (most often performed to diagnose empyema, or infection in the pleural space surrounding the lungs).

He would ask the patient questions:

• Have you been around anything new lately?
• Is there a history of this in your family?
• Is anyone else sick in your family? In your city-state?
• Has there been a change in winds recently?
• What is your job?

If the patient was unable to answer these questions, he would ask friends and family members.  The answers to these questions would determine what changes occurred to the humors inside the patients body.  This would then determine the cause and the cure.

If the patient was diagnosed with asthma, the cures were the same as for any basic ailment, and were generally meant to assist nature in the healing process.  Such remedies included:

• Bathing
• Breathing purified air
• Getting plenty of sleep
• Eating a specific and healthy diet
• Getting exercise

He also believed asthmatics should avoid whatever was thought to exacerbate it, and this may have been the best remedy of them all.  

If asthma did not improve with the basic remedies, only then would Hippocrates recommend other remedies, such as:

• Massage
• Glass of wine or Mandragora as a sedative
• Draught of white hellabore to induce a good purging to cleanse the system. 
• Bleeding (rarely)
• Inhaling herbs

Asthma historian Mark Sanders said that another remedy he might have prescribed was inhaling the fumes of various herbs "boiled with venegar and oil" through a tube.  (7)

He provided medicine with the first viable description of asthma and the first simple remedies.  His remedies were mainly palliative in nature, offering the patient hope as he waited for the asthma episode to dissipate.

References

1. Prioreschi, Plinio, "A history of medicine," vol II: Greek Medicine, chapter five, "Hippocrates," 2nd ed., 1996, NE, Horatius Press, 201-5
2. Sigerist, Henry E "A History of Medicine," vol I, "Primitive and Archaic Medicine," 1951, New York, Oxford university Press
3. Withington, Edward E, "Medical history from the earliest times: a popular history of the healing art," 1894, London, Aberdeen University Press
4. Watson, John, "The Medical Profession in Ancient Times," 1856, New York,
5. Fourgeaud, V.J, "Historical Sketches:  Galen," Pacific Medical and Surjical Journals, ed. Fourgeaud and J.F. Morse, Vol VII, San Franskisco, J Thompson and Co, 1864, page 22-29
6. Meryon, Edward, "The History of Medicine," 1861, Chapter II, "The Greek System of Medicine, From the Time of Hippocrates to the Christian Era."
7. Sanders, Mark, "Inhalation Therapy: An Historical Review," Primary Care Respiratory Journal, 2007, 16 (2), pages 71-81
8. Cotto, Bob, "Who Discovered Asthma: Hippocrates or Galen?" ezinearticles.com, http://ezinearticles.com/?Who-Discovered-Asthma-Hippocrates-Or-Galen?&id=1381520, accessed 11/1/13
9. Ryan, Michael, "Observations on the history and cure of the asthma:; in which the propriety of using the cold bath in that disorder is fully considered," 1793, London, Paternoster - Row
10. Jackson, Mark, "Asthma: The Biography," 2009, London, Oxford University Press
11. Hippocrates, "On Epilepsy," epitomised from the original Latin text by John Redman Coxe, 1846, "The Writings of Hippocrates and Galen," Philadelphia: Lindsay and Blakiston
12. Hippocrates, "The aphorisms of Hippocrates," translated by Thomas Coar, 1822, London, Printed by A.J. Valpy, Red Lion Court, Fleet Street
13. Hippocrates, "Airs, Waters and Places," translated by eminent scholars, 1881, London, Messrs Wyman and Sons 
14. Hippocrates, "The Sacred Disease," translated by Robert Maynard Hutchins, "Great Books of the Western World: Hippocratic Writings on the Natural Faculties, 1952,; also see Hippocrates, "On the Sacred Disease," translated by Francis Adams
15. Hippocrates, "Aphorism," section III, #22, translated by Robert Maynard Hutchins, " "Great Books of the Western World: Hippocratic Writings on the Natural Faculties, 1952, 
16. Hippocrates, "Aphorism," section III, #26, translated by Robert Maynard Hutchins, " "Great Books of the Western World: Hippocratic Writings on the Natural Faculties, 1952, 
17. Hippocrates, "Aphorism," section VI, #46, translated by Robert Maynard Hutchins, " "Great Books of the Western World: Hippocratic Writings on the Natural Faculties, 1952, 
18. Eadie, Mervyn J., Peter F. Bladin, A disease once sacred: a history of the medical understanding of epilepsy," 2001, England, John Libby & Company Ltd.
19. Hippocrates, "On the Sacred Disease," translated by Francis Adams