1819: Laennec accurately groups emphysema and bronchitis

Laennec accurately described emphysema (13)

Dr. Rene Laennec was known as the father of chest medicine, and this is mainly due to the fact he was the first to have the tools necessary to compare what he learned upon assessment of the chest during life, with what he saw when inspecting the lungs during autopsy after life.

The tools he had access to were chest percussion and the monaural stethoscope he invented. He used these to perform complete assessments of the chest on any of his patients who complained of asthma or asthma-like symptoms, such as dyspnea, chest tightness, chest pain, increased phlegm, and coughing. By doing this he became the first physician to accurately distinguish asthma from chronic bronchitis and emphysema.

That said, here is how he described bronchitis and emphysema.

Bronchitis:  He defined it as "Chronic Mucous Catarrh."

He said bronchitic airways are sometimes present with a "general or partial dilation of the bronchi.  Pulmonary vessels are often congested, and this can often be diagnosed by sputum that is tinged with blood. In fact, while the amount expectorated varies from day to day, colorful sputum is almost always produced. However, when the person becomes weak, expectoration may become difficult. (2, page 81)

He said bronchitis usually occurs in the aging, and usually after a severe acute attack, and as it worsens often produces dyspnea.  (2, page 83)

He said if it does occur in the young, however, it usually disappears in a year or two.  However, the only time it disappears in the aging is during the summer months, only to return during the winter months. In such cases it usually returns with a fever and copious expectoration.  After a few times of this happening... (2, page 83)

...it terminates in a continual mucous catarrh... the great expectoration of which weakens and emaciates the patient." (2, page 83)

Since he had access to his stethoscope, he would use it to help him diagnose chronic mucous catarrh.  He would generally hear "mucous rhonchus, sometimes indeed pretty loud and abundant, but very rarely continuous, and still rarely general over the chest." (2, page 83-84)

Laennec said emphysema has been described by some previous authors -- Bonetus, Morgagni, and Floyer,  who observed emphysema in a "broken winded mare" --although "none of these various authors appear to have been acquainted with the real character of the affection, viz -- dilation of the bronchial cells." (2, pages 161,165)

So he said it had never been accurately described. There were two exceptions to this, and these include Ruysh and Valsalva. (2, page 165)

Some might say that Dr. Ballie accurately described emphysema, but Laennec disagrees.  He said:

Dr. Baillie, author of the Morbid Anatomy, has correctly observed the three principal circumstances which constitute emphysema of the lungs, namely—the great size of these organs,—the dilatation of the cells,—and the vesicles formed by the extravasation of air under the pleura; but he does not appear to have been acquainted with the mutual dependence of these three states, and describes them as three different affections. (2, page 166)

In fact, he said that even he thought it was a rare disease until he started making use of the stethoscope.  Since then he said he has verified it in the living as well as the dead.  In fact, he became so adept at diagnosing it that he figured that many cases previously defined as asthma were actually emphysema.  (2, page 161, 163, 165)

He defined it simply as...

...dilation of the air cells... the cavity of these dilated cells descends some little way into the substance of the viscus, and there its walls do not collapse... the bronchial tubes, especially those of the small calibre, are sometimes very evidently dilated in those portions of the lung where the emphysema exists. (2, page 161-163)

He observed that while many of the cells were dilated, some were ruptured. Interestingly, Laennec said:

When we blow into an emphysematous lung, the dilated and projecting cells seem to become flatter the more they are distended, and fall down to the general level of the surface. This is owing to the greater relative extensibility and elasticity of the healthy cells, which in the first instance rise to the level of the dilated cells, and then fall below them, to their natural level. The continued projection of the dilated cells may be partly owing, also, to the difficulty with which the air escapes from them, more especially when the exciting cause of the emphysema is the dry catarrh. (2, page 163)

He also said:

On placing an emphysematous lung in a vessel of water, it sinks much less than a healthy lung; sometimes it floats on the surface with scarcely any obvious immersion."  (2, page 164) 

Laennec became the first to describe emphysema due to aging, and he was the first to define emphysema as tissue damage in the peripheral air passages. He further defined emphysema as a breakdown of tissue in the parynchema of the lungs as opposed to air trapped in the alveoli due to an obstruction such as occurs in asthma and bronchitis.

He said the disease could be diagnosed upon autopsy, although he further stated it could be diagnosed in life by using the stethoscope. He said:

The respiratory sound is inaudible over the greater parts of the chest, and is very feeble in the points where it is audible... from time to time, while exploring the respiration or cough, a slight sibilous rhonchus... by the displacement of the pearly sputa. (2, page 172)

He also noted other signs that emphysema should be diagnosed over asthma: (2, page 172)

• Diminished lung sounds
• The long continuance of the disorder (chronic)
• The severity of the habitual (chronic) dyspnea
• The asthmatic paroxysm occasionally occurring
• The cylindrical form of the chest (barrel chest)
• The slight lividity of the skin
• Occasional dry crepitous rhonchus on inspiration or with cough (inspiratory crackles due to secretions)
• Occasional crackle where the rhonchus is heard
• When the complaint is of long standing and the patient far advanced in life, the paroxysms become more frequent and severe

M. Andral suggests that the dry crepitous rhonchus described by Laennec was the first description of crackles "at the moment of rupture of the air cells."  In modern medical language, this would be crackles on inspiration due to the alveolar cells popping open.  This may have been the first description of this commonly heard lungsound. (3, page 173)

Interestingly, Laennec offers the following about the prognosis of this disease.

Pulmonary emphysema.  is not a disease of great severity.  Of all the varieties of asthma it is unquestionably that which affords to the patient the best prospect of long life. The long continuance and slow progress of the disease and the nature of its causes, render it possible to struggle against the organic lesion, and permit the functional disorders resulting from it to be kept within tolerable bounds (3, page 174)

In this way, it was Laennec who became the first to distinguish chronic bronchitis and emphysema as separate entities from asthma.  He was the first to speculate that they ought to be extricated from the umbrella term asthma, to become disease entities of their own with their own treatments.

References:

1. Petty, Thomas L, "The History of COPD,"Int. J. Chron. Obstruct. Pulmon. Dis., 2006, March; 1(1): 3-14
2. Laennec, Rene, "Mediate Auscultation," translated by John Forbes, Notes by professor Andral, 4th edition, 1838, New York, Samuel S. and William Wood
3. Andras, author of the notes in the book, "Mediate Auscultation, by Rene Laennec," ibid
4. Laennec, Rene, "A Treaties on the Diseases of the Chest and on Mediate Auscultation, " 1834, London (copius notes by John Forbes)

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1816: Laennec invents the stethoscope

Figure 1 --Rene Laennec (1781-1826).  Along with
crediting an old kid's game with giving him the idea of
creating his first stethoscope, he was also skilled with
the flute.  His memory and his musical skill  helped him
come up with the ingenious plan of rolling up paper into
a hollow tube.  He then used this to listen to lung sounds.
He later modestly chimed that he was amazed the device
wasn't invented years ago.  Hippocrates was known for
performing auscultation by placing his ear upon his
patient's chest.  A simple stethoscope would have
greatly benefited the ancient physician. (4, page xxiii)

Before the 19th century the only way for a physician to auscultate (hear) heart and lung sounds was to place his ear upon his patent's chest.  This would change thanks to a brilliant invention by French Physician Rene Laennec.

A procedure called Immediate Auscultation was probably used by priest/physicians in ancient Egypt, although it was first described for the medical community around 400 B.C. by Hippocrates.

Laennec quotes Hippocrates from De Morbis:

auYou shall know by this that the chest contains water and not pus, if in applying the ear during a certain time on the side, you perceive a noise like that of boiling vinegar. (4, pages 28-29) 

Immediate auscultation, or placing an ear directly on the chest of the patient, was never further investigated by the successors of Hippocrates, and therefore never became standard practice.  (4, page 29)

Not helping matters was the fact that most people did not take regular baths, and sick people were sometimes hot and wet from sweat.  Laennec said that it was flat out disgusting. (4, pages 29)

Also not helping matters was the fact that it was not gentlemanly to do this to a lady, and that fat tissue muffles sound.

When he was 38-years-old on a hot and humid day in 1816, Rene Theophile Hyacinthe Laennec was posed with all of these problems, yet the need to auscultate his patient's heart and lung sounds was essential.

He came up with an ingenious plan that helped him assess his patient, yet which also helped him improve the assessment skills for all physicians.

Who was Rene Laenec? 

Laennec was born on February 17, 1781, to to an an "advocate of the provincial courts, and held some appointments under government, in his native country (France)... Fortunately his son was heir of the more solid parts of his genius; without his wit, but without his volatility.  (1, page xix)

At an early age he was put under the care of his uncle, a clergy man in charge of the parish of Eliam, in the vicinity of Quimper.  However, after the French Revolution broke out his care was transferred to another uncle, Dr. Laennec of Nanates. (1, page xix)

Dr. Laennec was a man of highest respectability both as to talent and conduct, and directed the studies of his nephew with the interest and affection of a parent. The young scholar did credit to his friends and teachers; having obtained considerable distinction from his fellows at the chief school of the department of the Lower Loire, wither he had been sent by his uncle. Having completed his preparatory studies at this seminary, his thoughts naturally turned towards physic as a profession. He willingly engaged himself as the pupil of his uncle, and entered upon the study of his future profession with the zeal inherent in his character, and with success indicative of his subsequent eminence. Besides the instructions derived from his uncle, who was at that time senior physician of the hospital, and afterwards Professor of Medicine and Materia Medica at Nantes, he attended the courses of anatomy given by the surgeons of the same establishment, and is said, even at this early age, to have shown a decided predilection for morbid anatomy and clinical observation.(1, page xix)

Figure 2 --
Shown here:  Matthew Baille (1761-1823)
While under the tutelage of Corvisant,
Laennec became good friends with
Matthew Baillie.  Ironically, both were
famous for their studies of diseases of
the lungs, and both were diagnosed with
consumption,and eventually died of this disease.  

In 1800 he attended the medical school of La Charite, which was where he came to tutelage of a well respected and well known physician by the name of Jean Nicolas Corvisant.  He also became good friends at this school with Matthew Baillie, who himself would go on to gain great fame as a physician.  (1, page x)

He had actually gained recognition earlier in his career, for while in school he wrote a history of medicine, and, in the year 1802 at the age of 21, published articles that were well received by his fellow physicians.  (1, page x)

He opened a clinic in and began seeing patients.  In 1816 he was appointed chief physician to the Necker Hospital.  It was here where he was presented with the opportunity whereby he came up with an ingenious plan that changed medical diagnosis forever.  (1, page xxiii)

What was Laennec's ingenious plan? 

So on a hot and humid day in 1816, a 36-year-old physician by the name of Rene Laennec came up with an ingenious plan.

According to Kendall F. Haven in his book "One hundred greatest inventions of all time," Laennec was a "well established doctor and diagnostician of chest and abdominal disorders when he was asked by a fellow physician to assess an obese young woman with breathing difficulties." (2, page 96)

Not that it matters, but, for the record, the patient's name was Marie-Melanie Basset, and she was only 40.

Haven said:

Laenec's normal technique was to have the woman partially disrobe so he could place his ear against a hanker chief over her chest.  He'd listen to lung sounds over five spots:  the underside of each arm, each side of upper back, and upper breast bone. 

Figure 3 --
Gabriel Andral (1797-1876)
He was a French pathologist at the
University of Paris.  He is best known
for his work on blood chemistry.
Andral wrote the comments in
the margins of the 1838 edition
of Laennec's book.

Yet when he did this on this Marie, he heard nothing.  So he tried percussion, a method of tapping on the chest to check for dull or resonant sounds that might indicate certain diseases. Yet this method proved useless as well.

Thinking off the cuff, Haven said, he "grabbed 24 sheets of paper, rolled them tightly into a bundle, and secured them in shape with paste glue. He applied one end of this paste roll against the young woman's chest, and the other to his ear." (2, page 97)

Leanecc was "delighted" to learn he could hear the woman's heart and lung sounds better this way than with the unaided ear against her chest.  He was so excited at how simple a device could make this job so much easier that he set out to do a series of experiments to find metals and tubes that would aid his ear in hearing heart and lung sounds.  (2, page 96)

He actually wanted to name the device le cylindre claiming it was frivolous to name such a device.  However, his colleagues thought it should have a name, and they came up with some of their own. Yet once he decided he didn't like any of these names, he decided to call it a stethoscope.  Stethe coming from the Greek term for chest, and scope coming from the Latin term for aim.  (2, page 97)

His stethoscope was actually a monaural stethoscope, meaning that it had only one ear piece.  You can see a picture of his monaural stethoscope in figure 4.

How did Laennec come up with his idea?

In his book "A treaties on the diseases of the chest, and on mediate auscultation," Laennec recollected a little kid's game, and it was this that gave him an idea.

He wrote:

In 1816, I was consulted by a young woman laboring under general symptoms of diseased heart, and in whose case percussion and the application of the hand were of little avail on account of the great degree of fatness. The other method just mentioned (auscultating with an ear to the chest) being rendered inadmissible by the age and sex of the patient, I happened to recollect a simple and well-known fact in acoustics, and fancied it might be turned to some use on the present occasion. The fact I allude to is the great distinctness with which we hear the scratch of a pin at one end of a piece of wood, on applying our ear to the other. Immediately, on this suggestion, I rolled a quire of paper into a kind of cylinder and applied one end of it to the region of the heart and the other to my ear, and was not a little surprised and pleased, to find that I could thereby perceive the action of the heart in a manner much more clear and distinct than I had ever been able to do by the immediate application of the ear. (4, page 6)

Figure 4 -- Laennec's Monaural Stethoscope (1820).  It was an inch
and a half in diameter and a foot long, perforated longitudinally
by a bore three lines wide, and hollowed out into a funnel shape
at one end to the depth of an inch and a half. A plug of wood
was fitted into this hollowed extremity with a perforation through
it of the same diameter as that of the rest of the tube. The plug
was used in auscultating heart sounds, and discarded in
 stethoscopes made at a later date. It was made in two sections
for convenience of carrying. (6, page 626)  Perhaps it
 provided some solace to Laennec that he was diagnosed with
consumption using a stethoscope similar to this. Photo Copyright
Science Museum/ Science and SocietyPicture Library

So he thereby discovered that his invention was better for hearing sounds inside the human body than the ear alone.

What was the first stethoscope like? 

Laennec described his first stethoscope in his book Mediate Auscultation:

The first instrument which I used was a cylinder of paper, formed of three quires, compactly rolled together, and kept in shape by paste. The longitudinal aperture which is always left in the centre of paper thus rolled, led accidentally in my hands to an important discovery. (4, page 7)

He  also set off on a quest to study and perform experiments using the device, and he fine tuned it until he came up with a better product.  He trialed a variety of materials, lengths, and sizes of aperture, until he came up with the product he thought was idea.

He said:

In consequence of these various experiments I now employ a cylinder of wood, an inch and a half in diameter, and a foot long, perforated longitudinally by a bore three lines wide, and hollowed out into a funnel-shape, to the depth of an inch and a half at one of its extremities. It is divided into two portions, partly for the convenience of carriage, and partly to permit its being used of half the usual length. The instrument in this form—that is, with the funnel-shaped extremity,—is used in exploring the respiration and rhonchus: when applied to the exploration of the heart and the voice, it is converted into a simple tube, with thick sides, by inserting into its excavated extremity a stopper or plug traversed by a small aperture, and accurately adjusted to. the excavation. (See figure 2)  (10, page 7)

What other experiments did Laennec perform with his stethoscope?

While his binaural stethoscope made it easy for him to hear the various sounds inside the chest, he soon realized that he had a rare opportunity to advance upon what was already known about diseases of the chest.

This in mind, he used his new tool to study diseases of the chest, matching what he observed what he observed while his patients were alive with what he found on autopsy after death.  He said:

From this moment I imagined that the circumstance might furnish means for enabling us to ascertain the character, not only of the action of the heart, but of every species of sound produced by the motion of all the thoracic viscera, and, consequently, for the exploration of the respiration, the voice, the rhonchus (the sound of air flowing through diseased air passages), and perhaps even the fluctuation of fluid extravasated (leaked) in the pleura (sack around the lungs) or the pericardium (sack around the heart). (4, page 6)

Figure 3 -- Laennec listens to man with tuberculosis*

He took upon this opportunity to study diseases of the chest at the Necker Hospital where he also received patients at his clinic.  He therefore bravely came into close contact with some of the sickest and contagious people in France at the time, which can be seen in figure 3.  It was this type of dedication to his work whereby he contacted the disease that ended up ending his life.

How was the stethoscope accepted by Laennec's peers? 

Despite how useful he found this new tool in diagnosing and researching diseases of the chest, it was initially rejected by his peers in the medical community.

"What a ridiculous idea," his colleagues would say.  "We doctors are called upon for our brilliant medical minds.  To say we should carry some frivolous tool around with us is absolutely ridiculous and below us." 

This is a plate of the parts of the Laennec's stethoscope
as it appeared in the first edition of his book in 1819.
(4, pages 783) 

Another doctor wrote, "He that hath ears to hear, let him use his ears and not a stethoscope."

This was yet another example of a dogmatic and proud medical profession refusing to accept anything new or different. For thousands of years physicians rejected any scientific idea that opposed Galen's superstitions, and now they flat out rejected a tool that would allow them to do their jobs better.

Perhaps under the encouragement of Corvisart, Laennec published a book reporting what both he and Corvisart had learned about the diseases of the chest by using their new discoveries: chest percussion, vocal fremitus, and the stethoscope.

The book was published in 1819 and titled "De Auscultation Mediate, ou Traitt du Diagnostic des Maladies despoumons ct du Cceur, fonde principalement sur ce nouveau moyen. (A treaties on the diseases of the chest, and on mediate auscultation)" 

The book was well received, and, in 1821, it was translated into English by John Forbes (whose book was referenced in writing this post).

Slowly over the next few years his hard work payed off.  So even though he only lived six years after his discovery, he was able to see its acceptance before he passed away in 1826.

Perhaps there was no better evidence as to his tool's usefulness than by his own perseverance in studying the various diseases of the chest, a quest which may have ultimately cost him his life.  

Figure 4 -- Painting of Laennec using his stethoscope on a boy.
This picture was taken from a painting by Robert Thom,
copyrighted in 1960.  

Conclusion:

Laennec married in 1824 and had two children. However, he was only able to enjoy his young family for a short time.

He continued to work arduously at his clinic, both seeing physicians and performing research.

He also worked hard in perfecting the book he became famous for, releasing the second edition in 1826.  Subsequent editions were then published by John Forbes.

In the process of accomplishing this, along with his other duties as a physician and researcher, he became so exhausted that he was forced to give up his work and return to the home he was born in. Although some say he was simply tired from being ridiculed by his colleagues.

Either way, he was ultimately diagnosed with phthsis pulmonalis, which is the Latin form of consumption, or tuberculosis.  Ironically, he was diagnosed with the very same tool he invented.  Perhaps this was consolation, proof that the passion of his life's work was finally accepted.

He passed away on August 13, 1826,

In the ensuing years his invention adjusted by others, and eventually a stethoscope with two ear pieces (binaural) was invented. In 1852 George Camman fine tuned the stethoscope so it was similar to the models we use today.

References:

1. Forbes, John, The life of the author, translator of "A treaties on the diseases of the chest, and on mediate auscultation," a book written by Rene Theophile Hyacinthe Laennec, 1838, New York, Philadelphia, Samuel S., pages xix-xxiii
2. Haven, Kendall F, "One hundred greatest inventions of all time," 2006, U.S., Greenwood Publishing Group, Inc., pages 96-98
3. "Now I hear:  The history of the stethoscope,"  http://antiquemed.com/, 1998-2011, accessed 12/28/13
4. Laennec, Rene Theophile Hyacinthe, "A treaties on the diseases of the chest, and on mediate auscultation," translated by John Forbes, notes by Dr. M. Andral, 4th edition, 1838, New York, Philadelphia, Samuel S. and William Wood, Thomas Cowperthwaite and Company
5.  Barchers,Suzanne, "I've Discovered Sound," Brainworks, 2009, Leopard, page 9
6. Camman, Donald M, "Historical Sketch: Stethoscopes," A Reference Handbook for Medical Sciences, edited by Albert Henry Buck, by various writers, volume VI, 1888, New York, William Wood and Company, 626-628

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1784: Emphysema is further defined

Charles Badham (1813-1884)

After the term emphysema was coined in 1679 the quest was on to learn more about this disease. Perhaps some best knowledge was gained from an unexpected source in Dr. Samuel Johnson, although not until he was dead, and his autopsy was performed

In 1721 F. Ruysh provided the first detailed description of emphysema coupled with pictures in his book "Observations anatomica-chirirgicae."  (1, page 85)

In 1764, W.Watson described a case of emphysema in "On account of what happened upon opening the body of an asthmatic person."  He was quoted in "Physiologic Basis of Respiratory Disease" as saying:  (1 page 85)

"The lungs were enormously distended with air... this air was extravasate and had burst through the extremities of the bronchi and vesicular substance...  In a word the lung was truly emphysematous.  In several parts this had formed large bladders... The air getting loose in the substance in the lungs cannot be parted with expiration; it subsequently is retained there and the space it occupies prevents as much of the external air being received into the lungs as its own quantity.(1 page 85)(13, pages 145-147)

Watson also described the diseased condition of the heart.

The figure of the human heart is that of a cone, divided through its axis; but in this case, the heart's figure was altered, and was more compressed than usual; and its ventricles distended with grumous blood. Every other part of the body was in its natural state. (13, page 145)

He added:

From this examination we find that in this instance respiration was greatly disturbed... The varices of the pulmonary vein not only retarded the blood in its passage to the left auricle of the heart, but, occupying a much larger space in the lungs than they naturally should, they left less room for the minute ramifications of the bronchia to extend themselves and consequently a less quantity of air was taken in at every inspiration than was necessary for the ordinary purposes of life...  But the disorder of the lungs from the varices was made infinitely worse by the emphysema. For by the extravasated air possessing so large a portion of the lungs, and which the patient could by no means part with in expiration, very little room was left for fresh air in inspiration; the lungs, from the emphysema, and from the diseased state of the pulmonary vein, filling almost the whole cavity of the thorax. (13, pages 145-146)

He said that in life the man was seized with a troublesome cough, and shortness of breath with minimal exertion.  He said there was no cure for the man because there was "no method of discharging the extravasated air from the lungs." (13, page 146)

Dr. Samuel Johnson (1709-1784)

By 1784 Dr. Samuel Johnson was well known for his medical skills,  and he also well known for his breathing trouble. He was thought to have suffered from asthma since birth, and later he was determined to have died of fibrosis of the lungs.  (6)

At any other time in history this information would have gone down as a fact and that would have been the end of it.  However, Dr. Johnson was born into a time when the medical community was searching for answers about diseases, and so, before he died he gave permission for his lungs to be preserved and studied for science.  (6)

Dr. James Arthur Wilson was only 19 when he performed the autopsy on Dr. Johnson, and he described the following:

"On opening into the cavity of the chest, the chest did not collapse as they usually do when the air is admitted, but remained distended, as they had lost the power of contraction; the air cells on the surface of the lungs were also very much enlarged... the heart was exceedingly large and strong."

Based on this autopsy report, later physicians, upon examining it, determined that Dr. Johnson did not die of asthma, nor fibrosis, but of a disease that was barely known at the time: emphysema. He was also found to have suffered from cor pulmonale, which would have been the result of his heard working so hard for many years to pump blood through his stiff lungs. (6)

Matthew Ballie was a prominent British physician who inherited his father's anatomy school in 1783. Throughout his career he studied the bodies of diseased patients, including some specimens handed down to him, such as the lungs of Dr. Samuel Johnson.

Matthew Ballie (1761-1823)

In 1799 and 1807, Ballie  described emphysema with detailed pictures.  He described the condition as "enlarged air spaces" in the lungs, and lungs that did not collapse.

He published a book in 1793, "The Morbid Anatomy of Some of the Most Important Parts of the Human Body." It's believed to be the first book on pathology.

He described the lungs of emphysema patients, which included the following description of Dr. Johnson's lungs:

"The lungs are sometimes, though I believe rarely, formed into pretty large cells to resemble the lungs of an amphibious animal. Of this I have seen three instances. It is not improbable that this accumulation (of air) may break down two or three contiguous cells into one, thereby, form a cell of very large size." (5, page 2)

In 1814 British Physician Charles Badham became the first to use the term "bronchitis" to denote "inflammatory changes in the mucous membrane." (9?)

Bronchitis would soon "supercede" the term chronic catahrr when referring to chronic inflammation of the respiratory tract that resulted in a chronic cough and the spitting up of yellow or otherwise colorful phlegm.   (9)

In 1819 a French physician would invent a device called the stethoscope that would forever change the landscape of medicine, allowing for a more precise means of diagnosing pulmonary diseases in life, as opposed to waiting for an autopsy to take place.  The inventor would be Dr. Rene Laennec.

References:

1. Qutayba Hamid, Joanne Shannon, James Martin, "Physiologic Basis of Respiratory Disease," 2005, Montreal, page 85-99
2. Bhatia, K. Sujata, "Biomaterials for Clinical Application," 2010, London, page 100
3. Petty, Thomas L, "The History of COPD,"Int. J. Chron. Obstruct. Pulmon. Dis., 2006, March; 1(1): 3-14
4. Crellin, J. M.D., "Selected Items from the history of pathology," Am J Pathol. 1980 January; 98(1): 212.
5. Thurlbeck, Wright, "Thurlbeck's Chronic Airflow Obstruction," 1999, Canada, pages 1-6
6. Reich, Jerome M, "Convulsion of the lung: an historical analysis of the cause of Dr. Johnson's fatal emphysema," Journal of the Royal Society of Medicine, Vol. 87, December, 1984, page
7. Laennec, Rene, "Treaties of the diseases of the chest," 1821
8. Stokes, William, "The Diagnosis and Treatment of Diseases of the Chest," 1837, Dublin
9. Gee, Samuel, "Bronchitis, Pulmonary Emphysema and Asthma, " The Lancet, March 18, 1899, page 51
10. Klotz, Oskar, Wm. Charles White, ed., "Papers on the Influence of Smoke on Health,"  Bulletin #9, 1914, page 36
11. Christie, Ronald V, "Emphysema of the Lungs: Part II, British Medical Journal, Jan. 29, 1944, page 143-146
12. Cleveland, Geo. Henry, "The Clinical Review: AJournal of Practical Medicine and Surgery," Vol. VIII, April-Sept. 1898, Chicago.
13. Wilson, W., "An account on what appeared on opening the body of an asthmatic person," The Philosophical Transactions of the Royal Society of London, from their commencement, in 1665, to the year 1800, abridged with biographical illustrations by Charles Hutton, George Shaw, Richard Pearson, Volume XII, 1809, London, Printed by and for C. and R. Baldwin, pages 145-147

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1750-1850: Tuberculosis wreaks havoc

The industrial revolution swept across the civilized world from 1750-1850. New inventions improved agriculture, manufacturing, mining, transportation and technology, and this had a stunning effect on culture and economies.  The world was forever changed for the better, or so people suspected.

Yet while culture and economies improved, a vicious killer spread across this modern world.  No one knew what it was. No one knew where it came from.  No one knew what to do about it.  The killer was generally referred to as consumption, and if you got it you were probably doomed. 

Yet since people were ignorant about what it was, and what caused it, and how it was contacted, they didn't know that by getting together in poorly ventilated areas of mills and factories that they were breathing the contaminated air that was exhaled by people who had the disease.  They didn't know it was caused by a bacteria, and that the bacteria was transported through the air and was inhaled.  

They didn't know the disease was spread by sharing hanker chiefs, and by touching contaminated people.  They didn't know the disease was prevalent before the industrial revolution, but the disease was more of a random disease that occurred here and there by chance.

Yet with the beginning of the revolution, people gathered in small, poorly ventilated areas.  People moved to cities, right into the grasp of the killer.  They did this because they wanted to create a better life for themselves and their children, and they did this not knowing they were moving into the closed chambers of the rampant and killer beast that consumption was.

There were a variety of names for it. It was called scrofula (swollen lymph nodes), Pott's disease (TB of the bone, spine), the Great White plague (17th century Europe), consumption or phthisis (TB of the lung), lupis vulgaris (TB of the skin), Mesenteric disease (TB from non-pasteurized milk), white swelling (TB of bone), and King's Evil (TB of of lymph glands). Or sometimes it's simply referred to as "captain of the ship of death" or "captain of men and death. Later on it would become known as tuberculosis. (9) 

A plague swept through Europe in the 16th century, and during this time what Hippocrates referred to as phthsis was referred to as the Great White Plague. Yet it was usually described by scientists and physicians as either phthsis or consumption and sometimes even scrofula.
During the next 200 years thousands would be killed. Little was known about it other than it's symptoms. Usually, a patient was diagnosed by a physician only after the patient noticed he was coughing up blood. By this time the disease was near its later stages, and prognosis was grim.
Franciscus dele Bo Sylvius published a book in 1679 called the Opera Medica in which he made the association between nodules in the lungs with phthisis. Perhaps as a result, in the 17th and 18th centuries, there were many references to the disease being contagious, and many warnings about those infected with it. (3) 

Yet for the most part physicians thought it was hereditary, as which was no different from what Hippocrates thought way back in the 5th century B.C.

Giovanni Baptista Morgagni, an Italian anatomist who lived 1682-1771, wrote quite a bit about medicine in his later years. He warned that the condition might be an infection and he warned against doing autopsies on anyone infected with it. (1, page 2)

TB was called "White Plague"
in the 18th-19th centuries

Right around the turn of the 17th century a health edict in the Republic of Lucca in Italy warned:

"Henceforth, human health should no longer be endangered by objects remaining after the death of a consumptive. The names of the deceased should be reported to the authorities, and measures taken for disinfection.”(2)

English Physician Benjamin Martin published a book in 1720 called "A New Theory of Consumption."  He wrote that the disease was caused by "wonderfully minute little creatures." He believed these "creatures" enter the body and cause the symptoms.

Likewise, Martin believed that those in close proximity to the patient, particularly those talking to the person, should be careful.  He wrote:

It may be therefore very likely that by an habitual lying in the same bed with a consumptive patient, constantly eating and drinking with him, or by very frequently conversing so nearly as to draw in part of the breath he emits from the lungs, a consumption may be caught by a sound person... I imagine that slightly conversing with consumptive patients is seldom or never sufficient to catch the disease."

In 1793, Dr. Matthew Ballie published a book "Morbid Anatomy of Some of the Most Important Parts of the Human Body." (?check year and book) He provided a description of the lungs and many lung diseases. He wrote about consumption, and was among the first to note nodules in other organs other than the lungs.
In 1689 Richard Morton (1637-1698) used the term "tubercle" to describe lesions he saw in organs of those who died of consumption.

Rene Laennec was born in 1787 and contacted tuberculosis as a young adult. He became rapt in studying this disease during the course of his career as a physician. He is best known for his 1816 invention of the stethoscope.  He was also the first to master its use.  He was also the first to see tubercles in lung tissue of those patients?

In 1819 he published "A Treatise on Diseases of the Chest, and of Mediate Auscultation." He described how to use the stethoscope in assessing and diagnosing patients. He also discussed the pathology of many disease processes, including what was used it to describe symptoms during various stages of the condition.  He described the adventitious lung sounds heard in people infected with pulmonary diseases like consumption.

Laennec met his demise by the grips of tuberculosis in 1826 at the young age of 45.

Samuel George Morton (1637-1698) was a pupil of Laennec. In 1834 he published his own book titled "Pulmonary Consumption." This would be the first book on the subject published in the United States. (4, page 10). 

He recommended that the age old practice of bleeding patients who are coughing up blood was a "plan that has hurried thousands of patients to their graves by destroying the last remains of strength."

However, if the patient was of good strength with a good pulse, he recommended "ten or twelve ounces of blood, taken rapidly from a large orifice, may divert the current of the circulation and relieve the pulmonary congestion." (5, page 120).

He said this would work because the condition resulted in ulcers which dry and the blood becomes congested around these regions causing the ulcers to burst, and this is why these patients spit up blood. He believed bleeding prior to this happening would help prevent the congestion.
Other remedies may also help "promote absorption of the congested blood" Some of these include:

• Spirits of turpentine
• Elixir of vitriol
• Common salt
• Opium
• Sugar of lead
• Rest
• Diet of gum water and farinaceous food

He agreed with a Dr. Beddoes, who recommended a ride in the fresh air as treatment.  Morton quotes Beddoes:

"In haemoptysis and pulmonary hemorrhages, I never observed any bad consequence from traveling in a carriage: on the contrary, I have known these discharges to stop on a journey, though previously they had, for many days, occurred at least once in twenty-four hours."

Johan Lukas Schönlein (1793-1864) wrote relatively little during his life. However, he did write a doctoral thesis and two papers of 1 and 3 pages respectively.

Despite his lack of enthusiasm for writing, it was Schönlein who introduced the terms hemophilia and tuberculosis in 1839. The word "tuberculosis" was derived from "tubercle", a word introduced by Morton in 1689 to describe the characteristic lesions of consumption.

The mid 19th century was a time when many scientists and doctors were experimenting with microbes. In 1843 Dr. Klencke became the first to cause an animal to develop the condition by innoculating a rabit with "portions of miliary and infiltrating tubercles from a man. Klencke, after accomplilshing this result, did not continue his investigations, and they were consequently soon forgotten." (6)
Despite all the research that had been done prior to 1865, many physicians believed that each case of tuberculosis "rose spontaneously in predisposed people." (2) 

Yet it was in 1865 that a French military physician named Jean Antionne Villemin proved that tuberculosis was caused by an infecting organism.
He inoculated cattle with both human tuberculosis and bovine tuberculosis. (6)  He thus proved that the two diseases were of similar origin, and he proved that the disease could be transferred form a human to cattle and from cattle to rabbits.  (2)

Regardless of Villemin's work, the idea that tuberculosis was a spontaneous condition was ingrained in the minds of many medical experts who performed many experiments trying to prove Villemin wrong.  While it took several years, in the end Villemin's ideas won out.

Robert Koch (1843-1910) was the next to perform many experiments on tissue from tuberculosis victims to see if he could learn more about it and come up with a cure.  He invented a staining method that allowed him to see the tubercle bacillus.

Through "artificial cultivation" he was able to grow the bacillus.  He then proceeded to reproduce the characteristics of tuberculosis in animals.  He also identified different forms of the disease in various animals.

Slowly, as the deadliest disease in the history of mankind continued to wreak havoc, the civilized world was learning more about it.  It would remain one of the top causes of death in the United States and Europe until the 1930s, when all this wisdom would result in control of the beast.

References:

1. Norris, Charles Camblos, "Gynecological and Obstetrical Tuberculosis," 1921, New York, London
2. Koehler, Christopher W., "Consumption, the great killer," http://pubs.acs.org/subscribe/archive/mdd/v05/i02/html/02timeline.html
3. "History of TB," New Jersey Medical School, Global Tuberculosis Institute, http://www.umdnj.edu/ntbc/tbhistory.htm
4. Klebs, Arnold Carl, "Tuberculosis," 1909, New York
5. Morton, Samuel, "Pulmonary Consumption," 1834, Philadelphia
6. Flenner, Simon, , "Immunity in Tuberculosis," Annual report of the Smithonian Institution, 1907, New York, page 627 
7. "Captain of the Men of Death," Ulster Med J. 1989; 58(Suppl): 7–9.
8. Sigeris, Henry E, "A History of Medicine," volume I, "Primitive and Archaic Medicine," Second Edition, 1955, New York, Oxford University Press, page 53
9. Seth, Vimlesh, SK Kabra, Rachna Seth, "Essentials of Tuberculosis,"  Third ed., Jaypee Brothers Medical Publishing, 2006, page 3-4
10. Jones, Greta, "Ca;ptain of All These Men of Death," 2001, New York
11. Prioreschi, Plinio, "A History of Medicine," 1991, volume I, "Primitive and Ancient Medicine," Edwin Mellen Press, Chapter VII, "biblical Medicine," page 514
12. Landau, Elaine, "Tuberculosis," 1995, New York, Chicago, London, Sydney, Franklin Watts, pages 13-32

Photos:

• 1.  from  http://www.grantvillegazette.com/articles/The_White_Plague

Further reading:

• Essentials of tuberculosisi in children
• Johnson, H.A., "Consumption in the Northwestern States," The Chicago Medical Journal and Examiner, Volume 37, William M. Syford, et al, editors, 1878, pages 133-143

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