1819: Laennec defines pneumonia

By the year 1819, when Rene Laennec invented the stethoscope, little had changed regarding pneumonia since it was described by Hippocrates.  Treatment was also unchanged, as many physicians still recommended bleeding as a general treatment.

In his 1819 book, Mediate Auscultation, Laennec used his stethoscope to distinguish pneumonia from other pulmonary diseases.  He said that first it had to be separated from pleurisy, as calling it peripneumony as added to "confounded" descriptions of it. (1, page 512)

However Laennec continues to use the terom peripnumony.  He described three types of peripneumony. (1, pages 512-516)

1. Pneumonia complicated with slight pleurisy: It can be accurately diagnosed by crepitous rhonchus (fine inspiratory crackles) being heard over the part of the lung affected, which is usually the "roots of the lungs"
2. Pleurisy complicated with slight pneumonia: Crepitous rhonchus only at the roots of the lungs and the large bronchi
3. Pleuro-pneumonia: Pleurisy with severe pneumonia (1, pages 512-516)

The following are the recommended options: (1, pages 504-508)

1. Venesection, either general or local (to reduce congestion)
2. Cupping
3. No food for a few days
4. Getting out of bed several hours a day
5. Tartar emetic in large doses
6. Antimonials as an emetic
7. Kermes as an emetic
8. Mercury to treat inflammation 
9. Hot wine, brandy, and aromatics to treat fever
10. Blisters to the affected side to treat chronic pleuropneumony
11. Purgatives and diuretics, particularly when dropsy or hydrothorax occurs
12. Acetate of potass
13. Extract of squills
14. Watery infusion of digitalis
15. Nitre as a diuretic (1, pages 504-508)

Which of the above remedies is used, and the dosage, depends on the stage of the disease, and what comorbidities exist with it: does it present with a fever? Is it aucte or chornic? 

Pleurisy and pneumonia were pretty much treated the same, basically because they both present with inflammation.

References:

1. Laennec, Rene, "Mediate Auscultation," translated by John Forbes, Notes by professor Andral, 4th edition, 1838, New York, Samuel S. and William Wood, pages 84-87 for bronchitis treatment, and 175-177 for emphysema treatment
2. Andras, author of the notes in the book, "Mediate Auscultation, by Rene Laennec," ibid

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1820-1930: Pneumonia, the new "captain of the men and death

Thomas Addison (1793-1860

For most of human existence tuberculosis was known as the deadliest disease.  It was such a deadly disease by the 17th century, that John Bunyan (1628-1688), the famous author of "Pilgrim's Progress" referred to it as "the captain of men and death."  It wouldn't be until the early 20th century that tuberculosis would take a back seat to pneumonia.

While pneumonia has been present since the beginning of mankind, and the medical profession has been aware of it since the 5th century, little new information was learned about it.  It really wasn't until the end of the 19th century that physicians started to get a grasp on this disease.

Dr. Thomas Addison, a physician to Guy's Hospital in London,  was the first to write about pneumonia not being a disease that affected just the "interstices" of the lungs but the "air vessicles" themselves. (8, page 193)

Carl von  Rokitansky, a German physician, was the first to describe lobar pneumonia. (10, page 1308)

He said:

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, page 1308)

Various physicians described a pneumococcus associated with patients with lobar pneumonia.  (8,page 197)

Carl von Rokitansky (1804-1878)

In 1880 Sternberg found it in the saliva, and in 1881 Louis Pasteur discovered the same. (8, page 197)

In 1882 Ernst victor von Leyden and Gunther drew fluid from hepatized lungs of living pneumonia patients and discovered pneumococci in this fluid. (8, page 197)

Yet in all of these cases, the significance of the discovery went unnoticed.  (8, page 197)

It wasn't until 1875 that Edwin Klebs associated pneumonia with the bacteria, describing an "oval coccus" that he obtained from cases of lobar pneumonia. (8, page 197)(?)

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, in the early editions of his book, "The Principles and Practice of Medicine," mentioned using oxygen for emphysema and asthma, and by 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)

In 1901, in his popular medical textbook "The Principles and Practice of Medicine," Dr. Osler referred to pneumonia as the new captain of men and death. He wrote:

The most widespread and fatal of all infectious diseases, pneumonia, is now the "Captain of the Men and Death," to use the phrase applied by John Bunyon to consumption." 

 By 1918 pneumonia became the leading cause of death, overtaking tuberculosis. In describing the new leading cause of death, Osler burrowed from Bunyan, describing pneumonia as "captain of men and death. (4)

References:

References:

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
14. "Plutarch," britannica.com, http://www.britannica.com/EBchecked/topic/465201/Plutarch, accessed 7/20/14
15. Laennec, Rene, "Mediate Auscultation," translated by John Forbes, Notes by professor Andral, 4th edition, 1838, New York, Samuel S. and William Wood, pages 84-87 for bronchitis treatment, and 175-177 for emphysema treatment
16. Andras, author of the notes in the book, "Mediate Auscultation, by Rene Laennec," ibid
17. Reynolds, Arthur, R., "Pneumonia: The New Captain of the Men and Death," February 28, 1903, Journal of the American Medical Association," XL(9):583-586, http://jamanetwork.com/journals/jama/article-abstract/854678, accessed 1/2/16

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1600-1800: Physicians study pneumonia

After Hippocrates defined pneumonia in 400 B.C., little more was learned about this disease and its treatment.  The same was true of the Middle Ages, where the only discussion about it was by physicians living among the Eastern world.

Maimonides, a Jew living among Arabs, was a physician whose medical ideas were greatly appreciated.  He mentioned pneumonia, and said:

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 most accurate description of the disease up to this time, and the first to be remotely similar to the modern description of the disease.

Scottish physician and asthmatic William Cullen described pneumonia as either inflammation of the "viscera of the thorax or the membrane lining that cavity." (2, page 3)

 In 1792, Dr. Jean P. Frank mentioned that pneumonia "must be studied under the common name pleuro-pneumonia."(2, page 3)

While one cannot deny that 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 and diagnosed with the plague, many may have had their immune systems so wiped out that it was easy for pneumonia to set in.  (2, page 4-5)

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. (2, page 4-5)

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.

The death of the garrison of Philisbourg, in 1688,  was attributed to exposure to a "cold north wind... and camp life." (2, page 6)

Bleeding continued to be a common treatment for pneumonia.  Autopsies results on the garrison of Philsbourg ,and others afflicted with the disease,  described the lungs 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, page 6)

Hermann Boerhaave  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 recognized that pneumonia caused a solidification in a lobe of the lungs and referred to it as lobar pneumonia. (8, page 193)

John Huxham (1692-1768)

John Huxham, an English physician who wrote an "Essay on Fevers" in 1755, studied the writings of Hippocrates, Celsus and Aureatus, and, based on his own observations of diseases, came up with remedies for the 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 spent quality time performing post mortem studies, and he described many diseases of the lungs.  In 1793 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, page 193)

So we can see that, even heading into the 19th century, little changes had occurred regarding the description and treatment for pneumonia.

References:

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

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1885: Holzapple prescribes oxygen for pneumonia

George E Holzapple believed there were cases of pneumonia where oxygen may become deficient in the blood resulting in a condition called asphyxia.  When this happens the blood essentially becomes more venous, resulting in all the muscles of respiration being called into action, resulting in more breaths that were more frequent and deeper.  He said expiration becomes more marked, and the process ends in expiratory convulsions.  (1, pages 264-265)

He said that physiologists believed these expiratory convulsions were the response sent by the medulla oblongata of the brain as a result of asphyxia. (1, page 265)

He said the vaso-motor center of the brain will also have an effect on the vessels, causing them to become constricted, resulting in "increased arterial tension (high blood pressure) and the filling of systemic veins (bulging veins, edema). (1, page 265)

The heart will beat slower, but with more force, in order to do its job.  To pump blood through narrow vessels it pumps harder, but less frequently.  It ultimately poops out and becomes a weak pump. (1, page 265)

Blood continues to make it's way to the heart, but the heart is unable to pump it through the body.  The heart, therefore, becomes enlarged, or what he refers to as "distended."  He said that as "blood return to the coronary arteries becomes more venous, the contraction of the heart becomes more and more feeble," ultimately beating with less force. (1, page 265)

He said, "The phenomena result from an insufficient supply of oxygen in disease and in health. From the infrequency and feebleness of the heart's action, the blood accumulates in the heart, lungs, and great veins.  The heart is in danger of paralysis, from overdistension all as the result of lack of oxygen." (1, page 265)

Along with causing changes in the force and contractility of the heart, and the rate and depth of breathing, asphyxia also caused a bluish tinge of the skin where oxygen was low, which was referred to as cyanosis.  (1, page 266)

He postulated that since severe pnemonia may result in asphyxia and cyanosis, that perhaps these patients might benefit from intermittent  inhalations of oxygen.

 In the beginning of the winter of 1885, at York Hospital, he was asked to attend to a 16-year-old male who had a severe case of lobar pneumonia with cyanosis. This patient was not administered oxygen and died.

In March of the same year he was asked to attend to a 16-year-old male who also suffered from severe pneumonia, cyanosis and dyspnea (he was breathing at a rate of 75-80 breaths per minute), and who was begging for relief, Dr. Holzapple said he...

...resolved to administer the very element he craved.  In a few minutes after administering oxygen cyanosis became less, the patient expressed himself as somewhat relieved, and in twenty minutes his respirations were reduced from 75 to 60 in a minute. The effects on the respiration and his color were distinctly appreciated by the parents and those around the bedside of the young man.  I repeated the administration a number of times during that day until it was no longer needed. the patient recovered rapidly. (1, page 266)

He later took care of of 15-year-old girl with lobar pneumonia. When she presented with cyanosis and dyspnea on the seventh day, and after she begged for breath, Dr. Holzapple prescribed the administration of oxygen every 3-4 hours. The patient eventually died, but he was convinced the patient lived an extra 48 hours, giving nature a fighting chance, due to the oxygen therapy. (1, page 266)

He said he didn't expect the oxygen to cure patients with pneumonia, he expected that it would, however, "assist nature so that the patient may endure the effects of the disease till nature no more needs our assistance." (1, page 266)

His advice to physicians regarding oxygen was this:

To say that you are not prepared to administer it is no excuse when death is imminent, for every physician is as well prepared as I was, or soon can be at little expense. (1, page 266)

The problem with administering oxygen during this era was the difficulty in delivering it to the patient, as no standardization was in place.  Holzapple describes the method he used as rather "crude."  He said:

I generated oxygen from chlorate of potassium and black oxide of maganese, in large test tubes heated over a spirit lamp, and with rubber tubing I conducted the gas to the bottom of a deep bucket filled with water, which I had placed to the side of the patient's head.  Then with a fan the gas bubbling out of the water was wafted to the patient's face. (1, page 266)

He acknowledged that he was not aware he had become the first to recommend the administration of oxygen to patients with pneumonia.  In the two years following his experiments physicians became aware of the benefits of oxygen for pneumonia.  However, he said:

I am inclined to think, however, that the average county practitioner has very little medical literature that refers to the use of oxygen in pneumonia, which was one reason for writing this article. I advocate the use of oxygen not only in pneumonia, but whenever it is deficient unless for special reasons contra-indicated." (6 ,page 267) 

While Holzapple demonstrated the medical usefulness of oxygen,the apparatus he used was admittedly crude, yet it also did not deliver pure oxygen.  In fact, no device was yet invented that would deliver pure oxygen to the patient.  It would still be several years before adequate technology would be discovered to transport and administer it when needed.

References:

1. Holzapple, GE, "The uses and effects of oxygen gas and nux vomica in the treatment of pneumonia," New York Medical Journal, September 3, 1887, volume 46, pages 264-267

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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

400 B.C: Hippocrates defines pneumonia

Pneumonia is sometimes referred to as one of the oldest diseases known to mankind.  It would seem wise to presume that so long as a person, or a species, has lungs, that the possibility of them becoming infected, and inflamed, would always exist.  If this is true, then pneumonia must have been a common cause of death since the beginning of mankind.

During the rare opportunities that medicine men, or priest physicians, or later physicians, had to dissect a person who died of dyspnea or asthma, a whitish hue to the tissue of certain lobes, which may have been hardened, would have been observed.  They also would have observed colorful secretions in the airway.  In this way, it was easy for the first physicians to distinguish pneumonia from other diseases.  

Despite the disease going that far back, it wasn't described for the medical profession until Hippocrates wrote of it in 400 B.C.  However, we know that it was described long before him because he said it was "described by the ancients."

In attempting to distinguish between the two diseases, Hippocrates might try to shake the patient, a procedure called succussion.  This would allow the physician to hear the puss in the pleural cavity rattle.  He said any keen physician should be able to diagnose pleurisy by this method.

However, it must not have been that easy, as various Greek physicians, including Hippocrates himself, observed that it was difficult to differentiate between the two, and for this reason they were generally grouped together as peripneumonia, or peripneumony.  (8, page 192)

They knew pneumonia was inflammation in of one lobe of the lungs, and they knew pleurisy was inflammation in the pleural cavity.  Yet while pneumonia was accompanied by a fever and a pain in the chest, pleurisy was accompanied by a fever and a sharp pain in the side.

We now know that sometimes the two diseases appear independently of one another, although sometimes they appear together.  So its understandable that ancient physicians would have had trouble differentiating between the two, particularly lacking the ability to perform autopsies.

Of course, it was also quite common for both of these diseases to also be confused with asthma, which is our umbrella term for all causes of dyspnea other than pneumonia and phthisis.  So getting an accurate diagnosis was difficult regardless of the efforts of the physician.  (2, page 3)

Of peripneumony, 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.

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.

The treatment of Hippocrates was generally the same for all diseases, and consisted of good hygiene, a good diet, rest, exercise, and plenty of sleep.  These were supposed to help nature be the remedy, or the means of returning the humours to homeostasis.

However, if those did not work, and depending on the stage of the disease of the illness, age of the patient, color of the sputum, and season of the year, any of the following may be the remedies.  (6)

• 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

Hippocrates was well aware of when the disease was getting better or worse, as noted in the following passage.  (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."

Hippocrates noted that death from pneumonia usually occurs on the seventh day.

References:

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

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1920-1980: Pneumonia is finally tackled

For most of mankind, deadly diseases like influenza and tuberculosis were the main focus of the medical profession.  It was only when these diseases were tackled were physicians able to focus on other diseases, like pneumonia.

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 mold 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. These were exciting times among the medical profession, as for the first time in history physicians were able to hone in their surgical skills to the benefit of mankind.

This excitement was stymied somewhat during the 1960s and 1970s when physicians started observing a high incidence of post operative pneumonia, particularly among abdominal surgeries, and despite the use of antibiotics.

Similar observations were made among patients taking large amoungs of sedatives and narcotics.

It was quickly realized that further research needed to be done to determine the cause, and therefore a means of preventing these patients from developing pneumonia.

Studies soon concluded that humans were naturally inclined to action, that when a person was restricted to bed, this resulted in ill health.

That people naturally sigh 3-4 times in an hour in order to exercise the lungs and clear secretions, in an effort to keep the lungs sterile.  Sedatives, and painful surgeries, resulted in patients not taking deep breaths, and this resulted in an increase in the risk for developing pneumonia.

Preventative measures were then established, which mainly included having patients roll over, sit up, stand, and walk as soon as possible after surgery, even if the patients have to push themselves to the pain threshold.

Various devices were then invented with the intent of preventing alveoli from collapsing, and pneumonia from developing.  One device was a blowby device that encouraged patients to blow balls into jars.  Another device was called in incentive spirometer, which encouraged people to inhale and cough.

Morbidity and mortality for post operative pneumonia steadily declined.

Pneumonia in general declined when a pneumonia vaccine hit the market in 1977, and again when a pneumonia vaccine for children hit the market in 2000.

Thanks to all these innovations pneumonia is not the sixths leading cause of death, as opposed to the leading cause of death in the 1930s.

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.

References:

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
14. "Plutarch," britannica.com, http://www.britannica.com/EBchecked/topic/465201/Plutarch, accessed 7/20/14
15. Laennec, Rene, "Mediate Auscultation," translated by John Forbes, Notes by professor Andral, 4th edition, 1838, New York, Samuel S. and William Wood, pages 84-87 for bronchitis treatment, and 175-177 for emphysema treatment
16. Andras, author of the notes in the book, "Mediate Auscultation, by Rene Laennec," ibid

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