"Shortness of Breath" in Seneca: from philosophical astonishment to gene therapies

Lucius Annaeus Seneca, in his Epistulae morales ad Lucilium—especially Letter 54—portrays asthma not only as a bodily ailment but as a genuine "exercise in death" (meditatio mortis). The Stoic philosopher describes the asthmatic crisis as suspirium: a breath that falters, leaving the body in an anguished suspension. For Seneca, the loss of breath was the most concrete manifestation of human frailty: "Everything that must happen, happens at the moment when the breath fails."

In this sense, in Latin literature illness acquires a value that goes beyond the clinical fact and becomes a metaphor for the conflict between reason and biological precariousness. Seneca confronted the "disease" with the discipline of the will, attempting to master panic through philosophy—an attitude that, for centuries, remained the only real response to the limits of ancient medicine.

From this existential view of "shortness of breath" emerges a striking contrast with contemporary medicine. If in Seneca's time the sole defense was stoic endurance, today scientific research has transformed asthma from a frequently disabling condition into a disease increasingly controllable and amenable to personalized treatment.

The most significant breakthrough in recent years has been the introduction of monoclonal antibodies. Unlike traditional bronchodilators and corticosteroids, which act broadly on inflammation, biologic drugs—such as omalizumab and mepolizumab—target specific molecules of the immune system, including IgE and interleukins such as IL-5, IL-4 and IL-13. This approach enables treatment of severe eosinophilic or allergic asthma, substantially reducing exacerbations and improving patients’ quality of life.

At the same time, for patients who do not respond adequately to medication, bronchial thermoplasty has been developed: a minimally invasive technique that uses radiofrequency to reduce the thickness of bronchial smooth muscle. This limits the bronchi’s tendency to constrict and obstruct airflow during attacks.

The very way we conceive of the disease has also changed. Today we no longer speak of "asthma" in the singular, but of phenotypes and endotypes. Thanks to artificial intelligence and biomarker analysis—such as fractional exhaled nitric oxide (FeNO)—physicians can predict which treatments will be most effective for each individual, moving ever closer to truly personalized medicine.

Thus, while Seneca saw in every gasp a sign of impending end, contemporary medicine aims at clinical remission and prevention. Current research focuses on environmental factors and the pulmonary microbiota, with the hope of better understanding the disease’s root causes and preventing crises before they occur.

"The body is a temporary dwelling: one must leave it with the same spirit with which one entered it," Seneca wrote in his Epistles (120). Yet, thanks to scientific progress, that departure now seems much farther away and far less breathless.

Editorial written by professor Antonio Giordano for “Medicina gli Highlights” - column published in Il Mattino.