Monday, September 28, 2015

400 B.C-1600 A.D..: Pneumonia defined as a disease

Hippocrates (460-377 B.C.)
Pneumonia was one of the few lung diseases to have an official diagnosis in medicine, as it was described as far back as 400 B.C. by Hippocrates. Pneumonia was a term to describe "a condition about the lungs."

We know, however, the condition was known prior to the ancient Greeks, as Hippocrates said it was "described by the ancients."

Surely ancient physicians as far back as 1250 B.C. in Egypt would have inspected the lungs of dead men wounded in battle, and observed that they were soft and spongy and pinkish in color.  Yet upon the rare inspection of a person who died of dyspnea, observed the lungs to be hard with a whitish discoloration.

Since the condition presented with obvious scars and obvious symptoms in life-- dyspnea, chest pain, body aches, fever, diaphoresis, coughing, colorful sputum -- it was one of only two lung diseases not to be lumped under the rubric term asthma by the ancient Greeks (the other being phthisis).

Pleurisy is a condition where the lining around the lungs becomes inflammed, thus causing chest pain.  He described the condition in his book "On the Different Parts of man."  He said:
We known an empyema (pus in a cavity of the body, particularly the pleural cavity) by these indications.  A patient at first feels a pain in the side, pus collects, and the pain continues with cough and expectoration of pus, and difficult respiration. If, however, the pus has not yet found an exit, concussion (succussion) of the body renders it perceptible in its fluctuation, by a similar sound to that of fluid shaken in a bottle.  (5, page 239)
In other words, Hippocrates believed pleurisy or empyema could be diagnosed by shaking a patient, which was a routine procedure performed by him when a patient presented with shortness of breath and chest pain.

He continued:
When these signs are absent, and yet empyema exists, it may be suspected from the great oppression and the hoarse voice; the feet and knees swell, principally on the affected side, the thorax curves, lassitude is extreme, universal sweats, alternating cold and hot, the nails become crooked, a sense of heat in the abdomen, all of which are so many indications of an empyema. (5, page 239)
While ancient physicians were sometimes able to differentiate pneumonia from asthma, they were not so gifted at separating chest pain caused by pneumonia from chest pain caused by pleurisy.  For this reason, the conditions were generally looped together as peripneumonia.  (1, page 192)

Of this, Hippocrates wrote:
"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."
Hippocrates, in "The Different Parts of Man," section 1 chapter 1, and then again later in the book, said he believed diseases were caused by an imbalance of the four humors of blood, phlegm, black bile and yellow bile. Pneumonia resulted when the brain produced too much phlegm, and this phlegm overabundance of phlegm flowed to the soft tissues of the lungs.  While this might cause various pulmonary disorders, such as pneumonia, phthisis, pleurisy, cough, and thick sputum, he believed peripneumony resulted when both lungs were filled with the fluxation (flow, over abundance) of phlegms. Pleurisy results when one side is affected. (5, page 226, 228, 235, 238)(also see 5, page 268-270)

He believed pneumonia was the more severe of the two affections.  He said:
The pains are greater in the flancs and sides, the tongue is much paler, the throat suffers from the fluxion; the labour and oppression in respiration are extreme on the seventh or eighth day, death ensues from suffocation or weakness, or from both. If the fever, after diminishing for two days, returns on the ninth, death usually ensues, or else an internal suppuration has ensued; but if the fever is delayed, to the fourteenth day, the patient is safe. (5, page 238)
In "On Disease: Book III," he said that if peripneumony that if expectoration was sweetish by the eighteenth day, the lungs were in a state of suppuration (pus), and the condition would continue for a long time.  To diagnose suppuration, he recommended auscultation, which would have been done by placing an ear to the chest, as pus probably made a particular sound with each breath. Treatment for this was incision or cautery. (5, page 257, 260, 263, 266, 267)

The general treatment offered by Hippocrates for peripneumony would depend on the stage of the illness, age of the patient, color of the sputum, and season of the year.  Such remedies might include: (2, page 1)(3, page 481)
  • 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  (2, page 1)(3, page 481)
For pleurisy, especially where pus has formed, Hippocrates recommended paracentesis of the thorax, which was a painful procedure that involved removing pus from the pleural cavity. (5, pages 260, 266)

Hippocrates described how to remedy pleurisy and pneumonia in "On the Different Parts of Man."  First he described how to cure pleurisy.  He said:
The cure of pleurisy is as follows. Do not endeavour to check the fever before the seventh day; prescribe either oxymel or oxycrat for drink, and give it copiously, in order to facilitate expectoration by dilution; heating remedies are to be used to calm the pains, and to favour a discharge from the lungs. On the fourth day the patient must be placed in the bath; on the fifth and sixth he is to be anointed with oil, and on the seventh the bath is to be renewed, unless the fever is diminished, and thereby excite perspiration. From the fifth to the eighth day the most active expectorants are to be employed, if the disease progresses favourably. Should the fever not decline on the seventh, it ought to do so on the ninth, unless some dangerous symptoms supervene. When the fever terminates, we employ the weakest broths; if diarrhoea ensues, the system being still vigorous, we omit the drink, and give barley water if the fever has ceased. (5, page 240)
Second, he described how to treat pneumonia.  He said:
Peripneumony is to be treated in the same manner. In case of empyema, mild errhines, to excite a discharge from the nose, and thereby relieving the head, are to be employed, and such food as will loosen the bowels; if the disease is thereby arrested, and the humours diminish, we are then to promote expectoration, both by medicine and by appropriate food, by means of which coughing is excited. In order to effect this, the food should be of a fatty and saline quality, with wine of a rough character. Phthisical patients are treated in the same way, with the exception of giving less food at a time, and wine more diluted, so that the debilitated system may not be too greatly heated, and an afflux of humours thereby induced. (5, page 240)
He did describe fumigations (5, page 241) and an inhaler of sorts, although he reserved these remedies for non respiratory ailments. For instance, when a woman does not feel her infant moving inside her uterus, one of the treatments for this was, among other things, fumigation (of smoke or steam). Fumigation was also a remedy for pituituos menstration.  It was also a remedy for severe ulcers, among other similar non-respiratory ailments.  (5, page 300)

The point of these therapies was to reduce the amount of phlegm in the body to return the humors to a homeostatic state.

Hippocrates was aware of when the disease was getting better or worse.  He was quoted here by Jock Murray: (2, page 2)
"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. (2, page 2)( 1, page 191)

Hippocrates noted that death from pneumonia usually occured on the seventh day.  Areteaus of Cappadocia (about 140 A.D.) agreed with this.   He said, as quoted by Murray: (2, page 2)
"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 cures of Areteaus were similar to those of Hippocrates, although he adds: (6, page 2)(3, page 481)
  • Wine (when fever subsides)
  • Alkaline substances, such as soda, given in decoction of hysopp
  • Rubafacients containing mustard applied to the chest
  • Diluent drinks
  • Purging (6, page 2)(3, page 481)
Other ancient physicians described pneumonia and its remedies in a similar fashion as Hippocrates, including Celsus (25 B.C.-50 A.D), and Galen (120-210 A.D.) and Aetius (396-454).  Still, it was Galen's remedies  that were were what were copied by most physicians for the next 1800 years, including the Arabic physicians. (6, page 2)(3, pages 481-482)

By the 7th century it was understood that pneumonia was inflammation in the lungs. Paulus of Aegineta described it this way:
Peripneumonia is an inflammation of the lungs, supervening, for the most part, upon violent catarrhs, cynanche, asthma, pleurisies, or other complaints, but being sometimes the original affection. It is accompanied with difficulty of breathing, an acute fever of the ardent type, weight and tightness of the chest, a rale (wheeze), a seizure of the face with great fulness, the morbific matter being determined upwards like fire. Wherefore the cheeks appear red, the eyes swelled, with falling down of the eyebrows, and the cornea appears somewhat glossy.
Aegineta listed the following as his remedies, all of which continue to be similar to those of Hippocrates: (3, pages 480-481)
  • Clysters: Injected into the bowels, which are moved with difficulty
  • Cupping:  Large cupping-instruments with scarifications may be frequently applied to the breast and sides, but only when there are no contraindications
  • Bleeding:  If the peripneumonia was the original affection, and the strength permit, we must open a vein; or if not, we may cup, proportioning the evacuation of blood to the powers of the patient. 
  • Drinks: Draughts of the juice of ptisan, or of chondrus with honey, be taken, or from bitter almonds with semilago, or chondrus having some sweet potion mixed with it, such as hydromel, apomel, or hydrorosatum. Fresh butter to the extent of three spoonfuls is also proper. The patient must also drink the propoma of the decoction of figs with hyssop, or of iris boiled in honied water, or of powdered iris, to the amount of two spoonfuls sprinkled upon honied water. This also evacuates downwards. To keep up the strength, he should be made to drink frequently of honied water alone, and with pine-nuts, and the seed of cucumbers. 
  • Rubefacients: Cerate of the oil of rue and dried iris; or that made of wax, and rosin, marrow, butter, hyssop, dried iris, and nard ointment, may be applied to the whole chest and sides. 
Maimonides (1138-1204 AD) was the first physician to describe the signs of pneumonia similar to our modern description.  He said: (4, page 9)
"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, mostly (associated) with sputum." (4, page 9)
So while pneumonia was recognized at an early date in history, not much was added to our wisdom regarding this disease, other than the sporadic opinions of the various physicians, until the last few decades of the 17th century.

References:
  1. Allbutt, Clifford, ed, A System of Medicine, 1909, Toronto, chapter on "Lobar Pneumonia,"  by P.H. Pye-Smith, pages 191-205
  2. Marrie, Thomas J, editor, "Community Acquired Pneumonia," 2002, New York, Kluwer Academic Publishers, chapter one by Jock Murray, "The Captain of Men and Death: The History of Pneumonia."
  3. Aegineta, Paulus, "The Seven Books of Paulus Aegineta," translated by Francis Adams, volume I, 1844, The Snydenham Society
  4. Rosner, Fred, "The Medical Legacy of Moses Maimonides," 1998, NJ, KTAV Publishing House
  5. Coxe, John Redman, translator, "Hippocrates, the Writings of Hippocrates and Galen," 1846, http://oll.libertyfund.org/titles/1988, accessed 7/6/14, also see the book online at Google books, Philadelphia, Lindsay and Blakiston

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