COPD Before Modern Medicine: How COPD Healthcare Progressed to Where it is Today

For many people, it's difficult to imagine a world before modern medicine, even though such a world existed in the not-so-distant past. Even diseases like COPD, which we now know to be very common, were barely understood just a few generations ago.

In fact, the name “Chronic Obstructive Pulmonary Disease” is a fairly new term that wasn't used until the 1960's, which was only shortly after experts first decided on how to define the disease. That means that many people living with COPD living today were born before the disease even had a formal name!

Fortunately, the past several decades have brought huge advancements in respiratory medicine that have allowed more people than ever before to get diagnosed and treated for COPD. Getting to this point was no simple process, however; it took a concerted, multi-generational, and international effort to lay the foundation for COPD healthcare as we know it today.

In this post, we're going to take a closer look at COPD's storied history to see how COPD medicine has changed and improved over time. We'll discuss everything from centuries-old COPD studies to modern breakthroughs in COPD treatment, tracing the major events and turning points that happened along the way.

The history of COPD medicine is full of fascinating discoveries and brilliant minds working together to uncover the secrets of this complex disease. Throughout this guide, you'll learn about ancient physicians, misguided 19th-century COPD treatments, and how 20th-century innovations revolutionized healthcare for COPD.

Learning the tale of COPD's past can help us better understand the current state of COPD medicine and even gain some insight into the future of COPD care. Whether you have COPD yourself or are simply interested in the evolution of COPD medicine, the information in this guide will give you a new appreciation for the modern standard of COPD healthcare that millions of patients across the world rely upon every day.

COPD in Ancient Times: Early Discoveries and Interpretations

It's impossible to pinpoint an exact moment that COPD was “discovered,” since it was a gradual process that led researchers and physicians to recognize the disease. Until very recently, knowledge of lung diseases was very limited, and even the most expert physicians couldn't reliably tell the difference between different types of lung disease.

The earliest-known mentions of diseases that resemble COPD as we know it today go back all the way to the 1600's. However, it wasn't until the last century that it became possible to clearly define and diagnose COPD.

In the next sections, we're going to trace the origin of medical knowledge about COPD in pre-modern times up through the age of modern medicine. This will help us better understand how knowledge, perceptions, and theories about the COPD and respiratory medicine have gradually changed and grown more sophisticated over time.

Earliest Recorded Mentions of COPD (From B.C. times to 1700 A.D.)

The first known records of a COPD-like disease are found in the oldest medical document ever discovered: an ancient Chinese text known as the Nei Ching Su Wen (Classics on Internal Medicine) dating back to 2697 B.C. However, this text (like other B.C.-era documents) only references general symptoms (like shortness of breath) that could be attributable to asthma or another respiratory disease.

The first specific mentions come from the mid-1600's A.D, right around the time that autopsies were becoming acceptable in medical practice. This is when physicians appear to have first discovered the condition that we now refer to as enlarged or “hyper-inflated” lungs, which is a common characteristic of COPD.

The earliest of these references came from Swiss physician Theophile Bonet, who in 1679 described finding “voluminous” lungs in autopsies of patients who had suffered from shortness of breath. He was one of the first to recognize this trait as a distinct characteristic of a specific kind of respiratory disease (which would later be known as COPD).

Discovering the Role of Lung Inflammation in Respiratory Disease (The Late 1700's to Early 1800's)

Nearly a century after Bonet's original discovery of hyper-inflated lungs, influential Italian anatomical researcher Giovoanni Morgagni found additional evidence to corroborate Bonet's findings. In his 1796 book “The Seats and Causes of Diseases” Morgagni reported observing 19 separate instances of lungs that were “turgid”(or distended) with air (PDF link).

Around the same time, two separate autopsies of a physician known as Dr. Samuel Johnson revealed that he had “enlarged air spaces” in his lungs, which researchers at the time assumed was caused by asthma. However, later researchers who studied the published descriptions and illustrations of Dr. Johnson's lungs determined that the damage was actually the result of emphysema, a condition that was not known by physicians at the time.

At this point in history (the 1700's), medical researchers were only just barely beginning to understand chronic respiratory conditions and the effects they have on the lungs. However, these early discoveries set the stage for the research that continued throughout the 1800's, when doctors first began to understand the concept of lung inflammation—a critical biological mechanism in COPD.

For many years, lung inflammation was primarily associated with the term “bronchitis,” which was first used by Charles Badham 1814. Badham defined bronchitis as chronic coughing and excess mucus production which he (correctly) determined was caused by inflammation in the mucus membranes lining the lungs.

Five years later, French physician Rene Laennec built on this concept by describing the role that lung inflammation plays in a wide variety of respiratory conditions. He was one of the first to recognize that hyper-inflated lungs were caused by damaged air sacs (emphysema) and to differentiate bronchitis, emphysema, and asthma as separate conditions (they were often lumped together at the time).

Laennec also invented the stethoscope, which allowed him to study respiration more closely and produce the first detailed descriptions of abnormal breathing sounds caused by lung diseases. Today, stethoscopes are still used to check for breathing problems and monitor the condition of the heart and lungs in people with COPD.

By drawing important connections between lung anatomy and respiratory function, both Badham and Laennec played a major role in furthering medical understanding of respiratory diseases. In particular, they helped to explain the nature of lung inflammation and bronchitis, which was a major step toward understanding chronic bronchitis and its role in COPD.

Though concepts like lung inflammation might seem obvious today, these discoveries were impressive advancements considering the relative ignorance of medical practice at the time. To put it into context, neither “germ theory” (the fundamental concept that microorganisms like bacteria and viruses can cause disease) nor the use of antiseptics for sterilization were widely accepted until the 1890's.

Defining and Differentiating Different Types of Lung Diseases (The Mid-to-Late 1800's)

The term “chronic bronchitis” first appeared in 1837, when Dr. William Stokes first defined it as persistent lung inflammation that caused excess mucus production and a chronic cough. He was also the first to describe how changes in sputum color and texture related to respiratory illnesses—a concept that's still used to evaluate COPD symptoms today.

Stokes was one of the first to acknowledge the relationship lung inflammation and emphysema, observing that people often suffered from emphysema and chronic bronchitis at the same time. However, Stokes misinterpreted this as a causal relationship, believing (incorrectly) that chronic bronchitis could cause emphysema over time.

The next big leap in respiratory medicine came in 1846 when physician John Hutchinson invented the spirometer, a device designed to measure the volume of the lungs. Though Hutchinson's spirometer wasn't very sophisticated, it introduced the concept of using lung volumes and exhaled air to evaluate respiratory conditions. Later improvements to the spirometer would allow it to measure airflow in addition to lung volume, making it into one of the most important tools for diagnosing COPD and other respiratory diseases.

Respiratory medicine continued to progress steadily through the end of the century, though the next major breakthroughs wouldn't come until the 1900's. Improvement mostly came in the form of better anatomical knowledge and more specific terminology (e.g. using the term “alveoli” instead of simply “cells” to describe the air sacs in the lungs).

By the late 1800's, the medical community was largely aware of most of the individual mechanisms underlying COPD, including lung inflammation, chronic bronchitis, emphysema, and hyperinflated lungs. However, doctors and researchers didn't fully understand how all of those mechanisms worked together, nor did they have tools to effectively define or differentiate between different types of respiratory diseases.

This was also the time that researchers first began to recognize that inhaling toxic particles from the environment (such as coal dust and air pollution) likely played a role in lung health and lung diseases. This, along with the more nuanced understanding of respiratory disease mechanisms, set the stage for the improved lung disease diagnostics and treatment methods that would be developed throughout the following century.

COPD Enters Contemporary Medicine: Formally Defining the Nature, Scope and Causes of COPD

The 20^th century was a period of unprecedented progress in COPD healthcare and in medicine as a whole. It brought enormous advancements in disease diagnosis and treatment, including countless new medicines, therapies, and diagnostic tools. It's also during this time that modern theories, definitions, and treatment approaches to COPD really started to take shape.

Improving Testing & Diagnostics for COPD: Measuring Airway Obstruction

In the early 1900's, the medical community lacked both the tools and the knowledge to consistently and reliably diagnose COPD. Most people were diagnosed based only on symptoms (e.g. chronic cough, shortness of breath, and excess mucus) and a basic physical examination (e.g. checking for enlarged chest and abnormal breathing sounds).

One of the biggest leaps in COPD diagnostics came when researchers began using spirometer data as an objective measure of respiratory function. This became possible in 1950, when French physician Dr. Tiffeneau developed a new method—known now as FEV1—for measuring airway obstruction using a spirometer.

This method was based on the discovery that airway diseases could be separated into two main categories: restrictive (diseases that that make it difficult for the lungs to fill up with air all the way) versus obstructive (diseases that make it difficult to empty air out of the lungs fully). COPD and asthma are both obstructive lung diseases.

Thus Tiffeneau came up with idea for the FEV1 (forced expiratory volume in 1 second), which is essentially a measurement of how quickly you can push all of the air out of your lungs. A low FEV1 can indicate that the airways are obstructed, which is a sign of an obstructive lung condition like asthma or COPD.

This measure not only helped to differentiate restrictive lung diseases from obstructive lung diseases, but was also useful for measuring degrees of airway obstruction. Today, the FEV1 remains a vital tool for COPD diagnosis and is one of the primary methods used to measure the severity of the disease.

Naming COPD: Defining the Disease and Determining Criteria for Diagnosis

COPD as a disease in and of itself was still a muddy concept in the early 1900's; it still didn't have an “official” name nor a clear and consistent medical definition. Doctors and researchers at the time usually referred to the disease as simply “emphysema” (especially in the US) or “bronchitis” (especially in Britain). Some used descriptive terms like “chronic airflow obstruction” or “chronic obstructive lung disease,” names that are still used in some parts of the world today.

The well-structured definition of COPD that we are familiar with today is based on the definition created in 1959, when medical professionals congregated at the Ciba Guest Symposium to devise the first set of specific criteria for defining and diagnosing COPD (PDF link). The term COPD came into use just a handful of years later, when Dr. William Briscoe first used it 1965.

These were critical steps toward advancing COPD research and providing a higher standard of healthcare for people with COPD. With the name and the specific criteria for COPD now established, doctors and researchers now had the ability to diagnose, assess, and study the disease in a much more consistent and accurate way.

This step couldn't have come a moment too soon, as the number of COPD cases began to skyrocket in the mid-1900's. As it became clear that COPD was no longer a rare illness, but a growing public health crisis, there was more pressure than ever on researchers to investigate the disease's origins and come up with a coherent explanation for what causes COPD.

Discovering the Main Causes of COPD: Smoking, Air Pollution, and other Environmental Hazards

Though some early 19^th century researchers noted a possible connection between COPD and respiratory irritants like air pollution and coal dust, this theory didn't receive much attention at the time. It wasn't until the mid-1900's—when exposure to environmental hazards like smoking and air pollution was much more widespread—that researchers began to seriously investigate the link between environmental hazards and COPD.

The most popular theory throughout the 1800's and early 1900's was that coughing itself was the cause of COPD. Many researchers believed that coughing (and other activities like glass-blowing or playing a wind instrument) could cause emphysema and lung hyper-inflation by putting excessive stress and pressure on the air sacs in the lungs.

This theory was mostly put to rest in the 1930's, when it was contradicted by modern research indicating that inflammation was at the root of chronic lung disease. However, experts still didn't have enough information to form a cohesive theory about the causes of COPD or the lung inflammation associated with the disease.

Unfortunately, at the time that scholars were still trying to sort this out, most of the western world was seeing an unprecedented increase in the popularity of smoking. This was shortly followed by a dramatic and unprecedented increase in prevalence of COPD and lung cancer in the mid-late 1900's.

Even then, however, it took many years for researchers to interpret this phenomenon and realize that there was a causal relationship between smoking and COPD. It took even longer for this conclusion to gain widespread acceptance due to industry push-back and general public denial.

The first clues came from studies on lung cancer and smoking in the 1940's-1950's, which established that smoking could cause long-term damage to the lungs. This naturally led some to wonder if there might be a similar connection between smoking and COPD, a suspicion that further research quickly confirmed.

This research was led by Dr. Charles Fletcher (PDF link), a leading researcher in the rapidly-expanding field of COPD research in the mid-late 1900's. Dr. Fletcher was one of the first to study the connection between air pollution, smoking, and chronic lung disease, and played an instrumental role in organizing the CIBA guest symposium that first defined the medical criteria for COPD.

At the time of Dr. Fletcher's research, the most prominent theory about COPD was the so-called “British hypothesis” (PDF link), which claimed that repeated respiratory infections were the primary cause of COPD. This theory was based primarily on observation; doctors saw that people with COPD got frequent respiratory infections, and believed that respiratory infections were the cause of the disease.

While there is a grain of truth to this idea (frequent and severe respiratory infections, especially in early childhood, are a known risk factor for COPD), it was a classic case of mixing up cause and effect. The respiratory infections doctors observed were actually a symptom of COPD, not the cause.

Dr. Fletcher would eventually prove this by designing a high-quality prospective study that examined how the early stages of the disease developed in healthy adults. This not only made it clear that the respiratory infections happened after (rather than before) the disease's onset, but also that smokers were vastly more likely than non-smokers to develop COPD.

This study and others that followed formed the basis of Fletcher's theory that respiratory irritants, especially air pollution and smoking, were the primary cause of COPD. This theory has been confirmed by many studies since (PDF link), and today it is still the most widely-accepted explanation of the natural origins of COPD.

Fletcher's research also helped to clarify the relationship between emphysema (lung tissue damage) and chronic bronchitis (excess mucus production). He determined that one did not cause the other, but were separate processes with a common cause: lung inflammation caused by exposure to tobacco smoke, air pollution, and other respiratory irritants that cause COPD.

COPD Becomes More Common Than Ever Before

Before the 1900's, COPD was considered to be a relatively rare disease, though it was likely more common than it was thought to be at the time. By the end of the century, however, COPD would be one of the leading causes of death in the US and the fifth leading cause of death worldwide (PDF link).

This dramatic increase in COPD cases was largely due to an equally dramatic increase in smoking, which is the number one cause of COPD (by far) across the world. Consider that average per capita cigarette consumption in the US increased by more than 80,000 percent between 1900 and 1963, while COPD cases more than doubled in the following decades.

This increase in smoking was largely driven by the advent of cigarette manufacturing in the 1880's, which made smoking tobacco more convenient, affordable, and popular than ever before. But because most people don't develop COPD until older adulthood, the consequences of this didn't become obvious until the first generation of heavy smokers began to reach old age—which was around the mid-1990's.

Other environmental hazards also played a role in the massive increase in COPD cases, though a much smaller role than the increase in smoking. The 1900's saw increases in air pollution, noxious commercial chemicals, and occupational exposure to lung-damaging industrial substances (such as coal, asbestos, and silica dust), all of which are now well-known causes of COPD.

It's also important to acknowledge the role of increasing life expectancy, which for men in the US increased by more than 25 years between 1900 and 1999 (PDF link). As more and more people lived long enough to develop age-related diseases, it was inevitable that more and more people would get diagnosed with COPD.

Between 1990 and 2017, the number of people diagnosed with chronic respiratory diseases (including COPD) continued to increase worldwide despite an overall decline in smoking during the same period. This is largely due to changing demographics, however; as the world population got older on average during this period, there was an (expected) increase in the prevalence of age-related diseases like COPD.

Today, COPD is recognized as the fourth leading cause of death in the US and the third leading cause of death worldwide. However, because it's a disease that's not very visible to the general public, it's still doesn't receive the level of attention and awareness that many doctors and researchers believe it deserves.

Developing New COPD Treatments

Throughout the early-mid 1900's, COPD was still a new concept in medicine, and the root causes of the disease were still largely unknown. Because of this, there weren't many effective COPD treatments until the 1960's, when major advancements in respiratory medicine made it possible to develop therapies that directly targeted lung diseases.

Before this, doctors primarily “treated” COPD by suggesting lifestyle and behavioral changes. However, these suggestions were based on a very flawed an incomplete understanding of lung diseases and the factors involved in cardio-respiratory health.

For example, doctors would often advise COPD patients to avoid exercise and physical activity in order to reduce COPD symptoms and reduce strain on the heart. However, this advice was actually quite counter-productive, since we now know that physical activity can significantly improve heart function and COPD symptoms, while inactivity is detrimental to both heart health and COPD.

Other early treatments included using expectorants to help clear out excess mucus from the lungs and airways—a valid treatment for COPD symptoms that is still used today. Unfortunately, a general lack of knowledge about pharmacological drugs in the 1800's meant that many doctors prescribed dubious substances (e.g. opium, cannabis, and various topical ointments) rather than legitimate expectorant medications.

Another thing that doctors managed to get right in the 1800's and early 1900's was understanding that air pollution made respiratory diseases worse. Because of this, many doctors advised patients with chronic respiratory symptoms to move away from heavily-polluted cities to rural areas with cleaner, healthier air.

Oxygen therapy was first developed in the early 1900's by Dr. Alvan Barach, though it was mostly used to treat severely ill patients with pneumonia at first. It wasn't until the 1930's that doctors began to use supplemental oxygen as a treatment for COPD, and the first portable oxygen devices weren't developed until the 1950's.

Certain bronchodilator drugs (medications that work by relaxing the airways to make it easier to breathe) were also available during this time, though they weren't nearly as selective or effective as modern bronchodilator medications are today. Additionally, early inhalers used to deliver these drugs were not efficient, widely available, nor easy to use.

All of this changed, however, when portable metered-dose inhalers became available in the late 1950's. Metered-dose inhalers were simple, portable, easy-to-use devices that could deliver pre-measured doses of medications, making inhalers more reliable and effective than ever before.

The first specialized bronchodilator drugs were introduced right around the same time; these medications (known as beta-2-agonists) were both safer and more effective than their predecessors at relieving respiratory symptoms. This, in combination with the introduction of metered-dose inhalers, significantly improved the quality of treatment for COPD, asthma, and other respiratory diseases.

Today, inhalers are mass-produced and come in a wide range of drug formulations for different uses (e.g. long-term vs. short-term symptom management). Bronchodilator inhalers remain the single most effective and most commonly-prescribed medications for COPD today.

If you're interested in learning more about the different types of COPD inhalers and how they work, check out our comprehensive guide on COPD inhalers here.

COPD Treatment Standards Today

Though doctors had most of the tools and medications they needed to treat COPD effectively in the mid-to-late 1900's, there were no precise, comprehensive guidelines for how to use them. For the most part, doctors just had to use their own judgment to interpret drug data and COPD research and treat patients with COPD on a case-by-case basis.

Today, COPD treatment is largely standardized, meaning that there are concrete guidelines (written by teams of experts) that tell doctors exactly how to diagnose COPD, judge the disease's severity, and determine the best course of treatment for patients with COPD. The purpose of these guidelines is to help doctors treat their patients more effectively using consistent, evidence-based strategies and tools.

The first comprehensive, standardized COPD treatment guidelines were developed by the Global Initiative for Chronic Obstructive Lung Disease (GOLD), which was established in 1997 in response to growing concern about COPD as a global health crisis. The organization's mission was to reduce the burden of COPD by supporting COPD research, increasing COPD awareness, and improving both the prevention and treatment of COPD.

In pursuit of those efforts, GOLD's first objective was to assemble a team of experts to create a set of universal guidelines for diagnosing, managing, and preventing COPD. These guidelines would be based on expert consensus from distinguished health professionals in respiratory medicine as well as a variety of other fields, who would analyze and synthesize the best available research on COPD.

The resulting document (the “Workshop Report, Global Strategy for the Diagnosis, Management, and Prevention of COPD”) was only the beginning. In the years since, GOLD has continued to fund COPD research and release an updated set of COPD guidelines every year.

The GOLD COPD guidelines cover several critical aspects of COPD diagnosis and treatment, including:

• How to recognize and define COPD using specific clinical criteria.
• How to use spirometry data and other diagnostic tools to make COPD diagnoses, evaluate lung function, and determine the severity of COPD (e.g. stage 1, stage 2, etc.).
• Which COPD medications have been proven to be most effective for different symptoms and stiuations.
• Best practices for prescribing COPD medications, including recommendations for dosing, monitoring, adjusting, and managing the risks of various drugs.
• How to develop a comprehensive COPD treatment plan and reduce symptoms in patients with stable COPD.
• How to prevent and treat COPD complications, including lung infections, exacerbations, cardiovascular problems.
• How to manage every aspect of COPD care, including long-term treatment plans, smoking cessation, vaccination, oxygen therapy, surgical interventions, pulmonary rehabilitation and palliative care.
• Strategies for COPD prevention, including COPD screenings, public health interventions, education, and doctor-patient communication.

While GOLD's COPD treatment guidelines are not the only standards out there, they are by far the most influential. Most experts consider GOLD's guidelines to be the leading expert consensus on COPD treatment, and its standards have been adopted by doctors and medical organizations all across the world.

COPD Across the World

Most modern healthcare systems across the world operate very similarly, especially as medical practices (like COPD diagnosis and treatment) have become more standardized over time. However, there is still a great deal of room for interpretation and judgment in medicine, meaning that even doctors who work in the same hospital or medical practice often have different treatment approaches.

Because of this, the kind of healthcare COPD patients get can vary noticeably between countries, regions, and even between medical centers within the same local area. Even in regions that tend to follow international “best practices” (and not all do), local regulations, resources, and even healthcare philosophies can influence how healthcare professionals treat patients with COPD.

For example, research shows that COPD healthcare practices (including diagnostics and treatment) vary widely in Asian countries, largely due to a lack of healthcare resources and organizational support. Researchers blame this lack of standardization, in part, for high levels of under-diagnosis and under-treatment of COPD patients in China.

Another barrier is the lack of diversity in COPD research; it can be tricky to apply current COPD knowledge and guidelines to populations that haven't been studied thoroughly yet. After all, health needs and disease characteristics can vary between populations for a variety of different reasons, including differences in genetics, environment, lifestyles, and more.

For example, in most high- and middle-income countries (including the US), tobacco smoke is the number one risk factor for COPD. Because of this, the people most affected by COPD in these countries are people who smoke, who are often over-represented in certain demographic groups (e.g. in the US, smokers are more likely to be male, have low socioeconomic status, and/or live in rural areas).

By contrast, the main COPD risk factor in low-income countries is indoor air pollution, which largely comes from burning biomass fuels for cooking and heating. Because this risk factor affects smokers and non-smokers alike, non-smokers in low-income countries are much more likely to get COPD than non-smokers in high-income countries.

This can result in striking differences between countries in how the burden of COPD is spread out (or clustered) within the population. In Ethiopia, for example, studies show that women tend to be exposed to indoor air pollution more often men and also have a higher incidence of COPD.

As these examples show, COPD risk factors (and who those risk factors affect) can differ greatly between countries and populations. This—in combination with regional differences in medical resources, methodologies, and healthcare accessibility—leads to significant variation in the types and the quality of care available to COPD patients across the world.

Conclusion

Understanding COPD's history helps us not only understand the current landscape of COPD medicine, but also helps us appreciate how far COPD treatment has come over the years. After all, it's easy to take the benefits of modern healthcare for granted—particularly the things that happen “behind the scenes” of the doctor's office, such as the rigorous ongoing research, the use of precise and objective diagnostic criteria, and the availability of expert consensus guidelines for treating disease.

But even though healthcare for people with COPD is better today than ever before, there is still plenty of room for improvement. Just like most aspects of healthcare, COPD medicine is a work in progress that will most likely never be complete.

Luckily, GOLD and other COPD organizations continue to lead widespread efforts to understand COPD better and develop more effective COPD treatment strategies. As research continues in earnest, the future will inevitably bring new discoveries, innovations, and an improved standard of care for people with COPD.