Tuesday, May 01, 2012

A brief history of pneumonia

Pneumonia is inflammation of lung tissuePneumonia may possibly be the leading cause of death all time.  Surely other maladies popped their ugly heads from time to time, and surely tuberculosis gave it a run for it's money, yet one consistent and deadly malady throughout human existence is that of pneumonia.

Statistics show that from 1900 to 1937 pneumonia was annually either the number one or number two cause of death, with tuberculosis competing with it for the top spot.  (1)  Statistics prior to 1900 are sparse, yet one might be right to assume pneumonia was consistently a leading cause of death since the beginning of human existence.

Pneumonia is also among the oldest diseases to have a diagnosis in medicine.  The Hippocratic writers described the malady as far back as 400 B.C. in the Hippocratic Corpus.  Yet we know it was diagnosed much earlier than this, considering the Hippocratic writers credited pneumonia as being "described by the ancients."

Signs and symptoms of the disease would have been well known to Greek physicians, and for those who performed autopsies, evidence of the illness would have likewise been visible.  Hippocrates described the condition as such:

"Peripneumonia, and pleuricic affections, are to be thus observed:  If the fever be acute, and if there be pains on either side, or in both, and if expiration be if cough be present, and the sputa expectorated be of a blond or livid color, or likewise thin, frothy, and florid, or having any other character different from the common."
Dictionary.com describes pneumon as latin for lung or lung and pneuma as latin for lung.  So pneumonia refers to a condition of the lung.

Pleurisy was defined by the Ancient Greeks as inflammation of the pleural cavity, and they recognized symptoms of pleurisy and pneumonia as a sharp pain in the side.  Hippocratic writers simply grouped these two conditions together under the phrase peripneumonia. (8, page 192).  The condition may also have been confused with other maladies such as asthma or heart failure, which were generally grouped under the umbrella term asthma.  (2, page 3) 

During the ancient ancient world, there were essentially only three diseases that affected breathing, and they were tuberculosis, asthma, and pneumonia.  Pretty much everything else that caused breathing trouble was grouped under the umbrella term asthma, which was pretty much a generic term for shortness of breath.  Pneumonia was not asthma because even the ancients could see that parts of the lung was full of inflammation, secretions, and pus. 

Treatment might include any of the following, depending on the stage of the illness, age of the patient, color of the sputum, and season of the year (6)
16th century doctor bleeding a patient*
  • Bleeding
  • If fever, the bowels were opened with clysters
  • If pain, hot water in a bottle or bladder, a sponge of hot water, or cataplasm of linseed was applied to the hypochondrium
  • Linctus containing galbanum and pine fruit in Attic Honey or...
  • Sothernwood in oxymel
  • Oppaponax (a bitter resin with a garlic taste) mixed in oxymel
  • Drink of ptisan made from huskey barley and mixed with oxymel
The hippocratic writers were aware of when the disease was getting better or worse (6)
"When pneumonia is at its height, the case is beyond remedy if he is not purged, and it is bad if he has dyspnoea, and urine that is thin and acrid, and if sweats come out about the neck and head, for such sweats are bad, as proceeding from the suffocation, rales, and the violence of the disease which is obtaining the upper hand, unless there be a copious evacuation of thick urine, and the sputa be concocted; when either of these comes on spontaneously, that will carry off the disease."
Plutarch (46-120 A.D.)
Plutarch (46-120 A.D.) recognized that while pleurisy often accompanied pneumonia and may have been responsible for the pleuritic chest pain and fever, it sometimes occurred on its own.  He decided that the term peripneumonia was superfluous, and therefore referred to inflammation of the lungs as pneumnonia, and inflammation of the pleural sac as pleurisy. (6, 8)

Hippocrates noted that death from pneumonia usually occurs on the seventh day.  Areteaus of Cappadocia, about 140 A.D., concurred with Hippocrates that death usually ensues on the sevenths day.  He wrote about the usefulness of the lungs, and explained that certain maladies can cause havoc: (6)
"But if the lungs be affected,  from a slight cause there is difficulty breathing, the patient lives miserably, and death is the issue, unless someone effects a cure.  But in a general affection, such as inflammation, there is a sense of suffocation, loss of speech and breathing, and a speedy death.  This is what we call peripneumonia, being an inflammation of the lungs, with acute fever, when they are attended with heaviness of the chest, freedom from pain, provided the lungs alone are inflamed."
The cure Areteaus wrote about for pneumonia was similar to that of Hippocrates, although he added the following to the list of options:  (6)
  • Wine
  • Hysopp
  • Rubafacients containing mustard applied to the chest
  • Diluent drinks
Claudius Galen of Pergamum was an ancient Greek physician (120-210 A.D.) who became one of the most prolific writers of medicine after Hippocrates.  He wrote one of the most famous medical journals that was worshiped by physicians for 1500 years after his death.  He is believed to be the first to differentiate between pneumonia and pleurisy, although he continued to refer to them as peripneumonia. (6, page 2)  His remedies for the malady were similar to those of Hippocrates.

Maimonides (1138-1204 AD), whose medical writings were well respected for many years, described:  "The basic symptoms which occur in pneumonia and which are never lacking are as  follows:  acute fever, sticking (pleuritic) pain in the side, short rapid breaths, serrated pulse and cough."  This was the first recorded description of the same signs of pneumonia as we define it in modern times.

Even Scottish physician and asthmatic William Cullen (1710-1790) explained pneumonia as either inflammation of the "viscera of the thorax or the membrane lining that cavity."  In 1792 Dr. Jean P. Frank mentioned that pneumonia "must be studied under the common name pleuro-pneumonia."(2, page 3)

Octavius Sturges, in his book, "The Natural History and Relations of Pneumonis," explains that while one cannot deny historic accounts and descriptions of epidemics were accurate, the descriptions of the way people died were often eerily similar to what doctors of today would diagnose as pneumonia.    

So while people suffering from the Black Plague, for example, may actually have been infested with the disease, many may have had their immune systems so wiped out that it was easy for pneumonia to set in.  This may explain monk descriptions as cough, bloody spitting, diarrhea and vomiting and fever, catarrh, difficulty breathing, pain in the side, weakness, delirium and quite often death.

Sturges also describes how the garrison of Philisbourg in 1688 that was attributed to exposure to a "cold north wind... and camp life."  One common treatment was bleeding.  Autopsies on him and others inflicted with pneumonia (or what was diagnosed as pneumonia) were described as "actively inflamed and hepatised, and in many parts purulent, the chest and pericardium filled with bloody serum and polypi in the right auricle of the heart." (2)

Hermann Boerhaave  (1668-1738) published Aphorisms in 1709 and described that lobar pneumonia should be recognized as a separate disease from other infections of the lungs.  (6, page 3)

Giovanni Battista Morgagni (1682-1771) recognized, that pneumonia caused a solidification in a lobe of the lungs and referred to it as lobar pneumonia. (8)

John Huxham (1692-1768) studied the writings of Hippocrates, Celsus and Aureatus, and, based on his own observations of diseases, came up with remedies for various medical conditions. One thing of significance regarding Huxham is he was in ardent opposition to what he referred to as quack medical therapy.  For the treatment of pneumonia he developed a procedure called the "Huxham tincture."  It was a medicinal drink that was recommended by physicians for many years.

Matthew Ballie (1761-1823) spent quality time performing post mortem studies, and he described many diseases of the lungs.  He described the inflamed parts of the lungs (pneumonia) as being covered by a solid mass similar to a liver, and he referred to it as "hepatisation."  (8)  ( in his book "Morbid Anatomy of Some of the Most Important Parts of the Human Body," in 1793)

Dr. Thomas Addison (1783-1860) was the first to write about pneumonia not being a disease that affected just the "interstices" of the lungs but the "air vessicles" themselves.

Carl von  Rokitansky (1804-1878)  was the first to describe lobar pneumonia.  Rokatansky described that "The red inflammatory product becomes gray and compact and indurated.  The air cells contract over the granulations, coalesce with them round their circumference, and become obliterated, their tissue being changed into a fibro-cellular structure, in which, from the similarity of their organization, the granulations are most probably also merged." (10)

Throughout 18th century phlebotomy or bleeding continued to be a common treatment as it was during the time of Hippocrates.  Many examples of pneumonia or pneumonia-like symptoms were described in medical writings and autopsies.  It is likewise believed that an aging George Washington had acquired pneumonia. As a treatment he was bled, and many historians believe it was this bleeding that caused his death more so than the pneumonia.

Pneumonia symptoms were also described during influenza outbreaks, which suggest that the flu weakened the immune response to the point where pneumonia set it.  Such an outbreak occurred in 1762, 1775, 1782 and again in 1837.  Outbreaks became less common by the end of the 19th century, yet I would imagine it continued to be a leading cause of death, as it was documented as such when statistics were recorded in 1900.

 In all the above cases where influenza is believed to have lead to pneumonia, characteristic symptoms were described.  And following the cases that resulted in death, inflammation of the lungs was described in autopsy reports.

Various physicians described a pneumococcus associated with patients with lobar pneumonia.  In 1880 Sternberg found it in the saliva, and in 1881 Louis Pasteur discovered the same.  In 1882 Ernst victor von Leyden and Gunther drew fluid from hepatized lungs of living pneumonia patients and discovered pneumococci in this fluid.  Yet in all of these cases the significance of the discovery went unnoticed.  (8)

In 1875 Edwin Klebs became the first to associate pneumonia with bacteria. A few years later Karl Friedlander and Hans Christian Gram started working together in the morgue of a hospital in Berlin and added to Klebs work by identifying the specific types of bacteria associated with pneumonia.

In 1882 Friedlander isolated streptococcus Pneunomiae in the sputum of a patient inflicted with pneumonia, and in 1884 Gram isolated Klebsiella Pneumoniae in the sputum of a patient  inflicted with pneumonia.

The procedure that Gram described when writing of his discovery was later called the gram stain.  It's a technique where a small sample of the sputum is stained, and this causes the cell walls of the bacteria to turn a certain color so the bacteria can be clearly identified. 

This technique is still used in labs to this day.  Yet while Gram simply used the technique to identify bacteria in sputum samples, it's used today to distinguish between different types of bacteria.

In 1888 Nikolia Fedorovich Gamaleia was working in Pasteur's lab when he inoculated sheep and dog with pneumococcus and this caused lobar pneumonia in these animals.  This experiment proved that pneumococcus was the cause of lobar pneumonia.  Gamaleia is also credited in 1888 as discovering bacteriolysins that destroy bacteria.  (11)  He also worked with pasteur to improve the process of inoculation.

By 1891 interstitial changes may occur in acute lobar pneumonia and this may result in fibroid pneumonia (fibrosis of the lungs), and this will be chronic.  (10, page 1309)

In 1896 French student Ernest Duchesne discovered penicillin, yet the significance of his discovery went unknown, and the discovery was left hanging.

William Henry Osler (1849-1919) was one of the most famous physicians during the late 19th century and early 20th century.  His textbook, "The Principles and Practice of Medicine," was quickly accepted as a standard medical text by medical schools, and updated editions of this text were used until 2001.  For this and his other medical contributions he is often referred to as the father of modern medicine.

In the earlier editions he mentioned using oxygen for emphysema and asthma, and by the 1898, or the third edition, he finally recommended oxygen for pneumonia.  However, while he mentions oxygen as an option, he rarely prescribed it for his patients.

He wrote, "It is doubtful whether the inhalation of oxygen in pneumonia is really beneficial.  Personally, when called in consultation in a case, if I see the oxygen cylinder at the bedside I feel the prognosis to be extremely grave.  It does sometimes seem to give transitory relief and to diminish the cyanosis.  It is harmless, its exhibition is very simple, and the process need not be all that disturbing to the patient.  The gas may be allowed to flow gently from the nozzle directly under the nostrils of the patient, or it may be administered every alternate 15 minutes through a mask." (12)

By 1918 pneumonia became the leading cause of death, overtaking tuberculosis, and Osler referred to pneumonia as the 'Captain of men and death."  (4)  Osler borrowed the term from John Bunyon (1628-1688) who became famous for writing the Pilgrims Progress.  Bunyon used the phrase to describe consumption (tuberculosis), which was a diseases most commonly associated with death in his day.

In 1928 Sir Alexander Fleming observed that colonies of the Bacterium Staphylococcus that he was growing in a colony were dissolving.  He later discovered the plates had been infested by a blue-green mold, and he determined it was this molt that was responsible for the bacteria dissolving.  He later grew the mold in its pure form and discovered that it killed many different kinds of bacteria. (5)

The mold he used was Peiciillium notatum.  The importance of this discovery was not known until 1939 when Howard Florey and Ernst Chain isolated the active ingredient and developed a powdered form of it.  (5)  Several Eurpean and American scientists worked together to work on a therapeutic medicine that could be used to treat bacterial infections.

By 1941 they had succeeded, and penicillin studies were performed.  In 1944 antibiotics were made available to treat allied soldiers wounded on the battlefield.

Incidence of pneumonia started to decline in 1937 due to improved medicine. So oxygen therapy, coupled with penicillin, helped decrease the rate of pneumonia deaths.  Yet cases of pneumonia continued to be prevalent. 

For example, operations weren't commonly performed in hospitals until the 1950s when effective aneasthetics and breathing machines were made available. In the 1960s and 1970s physicians noted the high incidence of pneumonia after operations -- particularly abdominal surgeries -- despite the use of antibiotics. Similar observations were noted among patients taking sedatives or pain relievers such as morphine.

Further study helped researchers determine the reason was because due to pain, or due to the sedatives,  these patients weren't taking deep enough breaths, and weren't adequately coughing.  This helped to create a breeding ground in the lungs for certain bacteria. Post operative pneumonia was learned to complicate treatment, prolong hospital stays, and even cause death.

To treat this, the incentive spirometer was invented.  The goal of this device was to encourage post operative patients to take deep breaths followed by a breath hold and a good cough.  It was also recommended that post operative patient get out of bed and start moving as soon as possible after surgery to prevent pneumonia. 

So the incidence of pneumonia took a sharp decline, and deaths likewise declined.  When a pneumonia vaccine hit the market in 1977 pneumonia rates declined a little more.  By 2000 a pneumonia vaccine became available for children, and this helped decline pneumonia deaths to its current level as the sixth leading cause of death.

Pneumonia is a malady that has been prevalent since the beginning of time.  Throughout the 20th century scientists found evidence of this in various Egyptian mummies from 1250-1000 B.C. that were shown to have pneumonia and other diseases of the lungs.  In one case of mummy pneumonia, the mummy was found to have a bacillus similar to the plague.

It's true that pneuomonia will continue to inflict people with diminished immune systems, such as the elderly and sick.  Yet with a growing plethera of medical knowledge, physicians have been able to greatly reduce the incidence of this disease, and in the process, prevent many deaths from the malady.

  1. "Leading Cause of Death, 1900-1998," http://www.cdc.gov/nchs/data/dvs/lead1900_98.pdf
  2. Sturges, Octavius, "The Natural History and Relations of Pneumonia," London, 1876
  3. "History of Pneumonia," The British Medical Journal,  Jan. 19, 1952, pages 156-158
  4. Schmitt, Steven K., "Oral Therapy for Pneumonia:  Who, When, and With What?" editorial, Journal of Clinical Outcomes Management,  March, 1999, vol 6, No 3, pages 48-50
  5. Bellis, Mary, "The History of Penicillin," http://inventors.about.com/od/pstartinventions/a/Penicillin.htm
  6. Marrie, Thomas J, "Community Acquired Pneumonia," 2001, New York, chapter one by Jock Murray, "The Captain of Men and Death: The History of Pneumonia."
  7. Auld, A.G., "The Pathological Histology of Bronchial Affections," The Lancet, Aug. 6, 1892, page 312
  8. Allbutt, Clifford, ed, A System of Medicine, 1909, Toronto, chapter on "Lobar Pneumonia,"  by P.H. Pye-Smith, pages 191-205
  9. Addison, Thomas, "A Collection of the published works of Thomas Addison," 1868, 
  10. Auld, A.G., "Fibroid Pneumonia," The Lancet,  June 13, 1891, page 1308-1310
  11. "Nikolai Fedorovich Gamaleia, The Free Dictionary by Farlex, http://encyclopedia2.thefreedictionary.com/Nikolai+Fedorovich+Gamaleia
  12. Osler, William, "The Principles and Practice of Medicine," 1898, 3rd ed., New York
  13. *Photo compliments of sciencephotolibrary.com


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