To the Editor:
I read with pleasure the excellent January 1999 issue of Pediatric Annals on asthma. I enjoyed Dr. Altemeier's editorial in that issue, but I disagree with his statement that asthma was a rare disease before the 20th century and that descriptions of asthma were rare before 1700.1 The term "asthma" has been used in many medical writings since the time of Hippocrates. Granted, many of the diseases described as asthma were actually other disorders (eg, emphysema, congestive heart failure, or tuberculosis). However, I think there is little doubt that asthma, as we know it today, existed then.
The word asthma is derived from the Greek doθµα, meaning to breathe hard.2 Asthma is mentioned several times in the Hippocratic Corpus, a collection of approximately 60 medical treatises that were written between 430 and 330 BC.3 In one essay in that corpus, the Regimen in Acute Diseases, asthma is described as follows:
Because the sputum becomes viscid and unripened, expiration is impeded causing wheezing in the bronchial tubes and thus, as has already been said, increased frequency of respiration leads rapidly to asthma, (p. 190)
In The Aphorisms, which Hippocrates (circa 460 BC) most likely wrote himself, both aphorism 26 and aphorism 30 mention asthma.4 Although the ancients referred to any disorder that caused dyspnea as asthma, certainly the respiratory problem noted in the quotation above is most consistent with true asthma.
The celebrated Arabian physician Avicenna (980-1037 AD) wrote the following in his canon of medicine5:
At all ages there is a tendency to asthma, spasmodic diseases (tetanic spasm, epilepsy), because there is a tendency for serous humor to accumulate in the head. (p. 208)
Approximately 100 years later, Moses Maimonides (1135-1204 AD), a Jewish physician and philosopher who, for many years, was the personal doctor to the Sultan of Egypt and his family, wrote an extensive treatise on asthma.6 In that work, he stated the following:
I conclude that this disorder [asthma] starts with a common cold, especially in the rainy season, and the patient is forced to gasp for breath day and night, depending on the duration of onset, until the phlegm is expelled, the flow completed and the lung well cleared. (P- 2)
In 1698, Sir John Floyer, a longtime sufferer from asthma, published his treatise on asthma.7 He was one of the first physicians to both differentiate asthma from other respiratory disorders and ascribe the cause of the dyspnea to bronchial obstruction. He wrote the following:
When the Muscles labour much for Inspiration and Expiration thro' some Obstruction, or Compression oí the Bronchia, etc. we properly call this a difficulty of breath: but if this Difficulty be by the Constriction of the Bronchia, 'tis properly the periodic Asthma: And if the Constriction be great, it is with Wheezing; but if less, the Wheezing is not so evident, (p. 249)
In conclusion, asthma is not a relatively new disease, although I agree that it has recently increased in prevalence. I suspect that it has been a common affliction, wreaking havoc on the health of many since the time of antiquity.
1. Altemeier WA II. Asthma: something is wrong. Pediatr Ann. 1999;28:14-15.
2. The Compact Oxford English Dictionary. Oxford, England: Clarendon Press; 1994:81.
3. Hippocrates. Regimen in acute diseases. In: Lloyd G, ed. The Hippocratic Writings. London: Penguin Books; 1983:190.
4. Hippocrates. The aphorisms of Hippocrates. In: Lloyd G, ed. The Hippocratic Writings. London: Penguin Books; 1983:215-216.
5. Avicenna. The Canon of Medicine. Birmingham, England: Gryphon Editions, Ltd; 1984:208.
6. Maimonides M. Treatise on asthma. In: Munter S, Rosner F, eds. Selected Medical Writings of Moses Maimonides. New York: Gryphon Editions; 1997:1-101.
7. Sakula A. Sir John Floyer's a treatise on the asthma (1698). Thorax. 1984;39:248-254.
Edward R. Carter, LTC, MC
Chief, Department of
Department of Pediatrics
Madigan Army Medical Center
Dr. Altetneier's response:
The question of whether asthma was rare until recently is important.1 If true, it should help us pin down what has caused asthma's dramatic increase during the past two decades. It is not possible to determine whether The Encyclopedia of Medical History was correct when it reported that historians had been able to find only 11 descriptions of asthma in the world literature before 1700.2 The historians may have missed reports, and it is difficult to separate respiratory distress with a productive cough due to asthma from that of pneumonia or other etiologies. One would expect that the recurrent nature of asthma attacks, separated by symptom-free intervals, would have been noted often if asthma were as common as today, but this does not seem to be the case. An equally important and more answerable question is: Is asthma really rare now in developing countries?3,4
Thank you for your input, Dr. Carter.
1. Altemeier WA III. Asthma: something is wrong. Pediatr Annals. 1999;28:14-15.
2. McGrew RE. The Encyclopedia of Medical History. New York: McGraw-Hill; 1985:9.
3.Cookson WOCM, Moffatt MF. Asthma: an epidemic in the absence of infection? Science. 1997;275: 41-44.
4. Vogel G. New clues to asthma therapies. Science. 1997;276:1643-1646.