100 B.C.- 200 A.D. Ancient physicians recognize pneumonia

Plutarch (46-120 A.D.)

After Hippocrates introduced the medical world to pneumonia around 400 B.C., little was changed regarding how it was defined and treated.

Plutarch was a Greek author who wrote over 227 works, including 60 essays on ethical, religious, physical, political and literary topics.  (1)

He 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. (2) (8)

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) (3, page 191)

Areteaus of Cappadocia, one of the ancient authors who helped us define asthma and how it was treated by the ancient world, concurred with Hippocrates regarding peripneumony, noting that death usually ensues on the sevenths day.

He wrote about the usefulness of the lungs, and explained that certain maladies can cause havoc: (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 cure Areteaus wrote about for pneumonia was similar to that of Hippocrates, although he added the following to the list of options:  (2)

• Wine
• Hysopp
• Rubafacients containing mustard applied to the chest
• Diluent drinks

Claudius Galen of Pergamum, who was perhaps the most significant medical authority of the ancient world, also differentiated pneumonia from pleurisy, although he continued to refer to them as peripneumonia. (2, page 2)

His remedies for the malady were also similar to those of Hippocrates.  So the greatest medical mind of the 2nd century, and whose works were worshiped by physicians for the next two millennium, had no desire to add to the wisdom of the ancient Greeks, at least regarding pneumonia.

References:

1. "Plutarch," britannica.com, http://www.britannica.com/EBchecked/topic/465201/Plutarch, accessed 7/20/14
2. Marrie, Thomas J, "Community Acquired Pneumonia," 2001, New York, chapter one by Jock Murray, "The Captain of Men and Death: The History of Pneumonia."
3. 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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9 B.C.: The first mouth to mouth respirations

This painting from the early 1920s depicts Elisha after
he gave mouth to mouth breaths to revive a Shunamite boy

Mouth-to-mouth breathing was a technique that must have been trialed from time to time by ancient physicians as a last ditch effort to save a life. When it was first attempted will forever remain a mystery, although the first known description of it appeared in the Bible in the Second Book of Kings.

Elisha was born in 9 B.C. When he was a young man he met the prophet Elijah and became his faithful disciple. Elijah at this time was a very old man: he was something like 841 or 821 years old according to the Bible.  

While still a young man he observed his master lifted up to Heaven in a fiery chariot, and he said, "My father, my father, the chariot of Israel...!"  At that moment he stripped off his clothes and declared that he was the successor of Elijah, and his job was to spread the word of the Lord.

The Bible described him as performing many miracles through the guidance of the Hebrew God.  In the Second Book of Kings he is described as successfully resuscitating (or reanimating) the child of a Shunamite woman with mouth to mouth breathing:

And he went up, and lay upon the child, and put his mouth upon his mouth, and his eyes upon his eyes, and his hands upon his hands: and he stretched himself upon the child; and the flesh of the child waxed warm. Then he returned, and walked in the house to and fro; and went up, and stretched himself upon him: and the child sneezed seven times, and the child opened his eyes. (II Kings 4: 34-5)

The depiction here may have been the first recorded use of mouth to mouth breathing. This would entail the physician, in this case the prophet Elisha, placing his mouth over the child's mouth and nose, and exhaling. This would force a positive pressure breath into the child's air passages, thus providing the child with an artificial breath. This procedure may have been performed, albeit rarely, in both the ancient and primitive worlds.  (1)

This scene is estimated to have appeared during the 8th century before the birth of Christ. It is highly likely the procedure was learned by Elisha while he was in training, as most learned individuals of this time were educated in all knowledge of the day, including medical wisdom. So it is highly likely the procedure was tried before in a last ditch effort to save a life.

References:

1. Price, J.L., "The Evolution of Breathing Machines," Medical History, 1962, January, 6(1), pages 67-72; Price references The Bible, Kings, 4: 34

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100 B.C.: The beginning of the decline of wisdom

In order to understand the medicine of a given point in time, it's essential to understand the people of that time.  So here is a glimpse into the era of ancient Rome at the time when Christianity was just forming.

The ancient Greeks significantly advanced wisdom for the ancient world, and this knowledge was a gift handed to the Romans. The problem was that the gift was only available to the chosen few, while the majority continued to live in abject poverty.

This is key here, because the way the Roman majority was treated by the ruling class would help set up the entire structure of the Jewish way of life. This lead to the planting of the seeds of Christianity, which slowly grew into a full and flourishing tree that provided hope to the majority, although at the expense of wisdom.

So, life for the majority was not very good. This was explained best by medical historian Thomas Lindsley Bradford in his 1898 book "Quiz questions on the history of medicine:"

Draper tells us that just before the coming of Christ Rome was very wicked. Rome then contained two millions and a quarter of inhabitants, but of these only about ten thousand were of the gentry, the upper ten; there were about one hundred and twenty-five thousand populace or plebs. The plebs were often paupers in feeling, many of them were given public alms; they had cheap board, free admission to the theatres and gladiatorial shows, where the combats of the gladiators was not calculated to impress with fine feeling. There was about a million slaves, held as chattels, in the most abject misery. They might be killed at the will of their masters, and sometimes they were horribly mutilated, the physicians often having to perform these acts. There was no middle class at Rome. All these were kept in order by the numerous guards, generally mercenaries and foreigners. In Caesar's time, Rome the city which ruled the world was terribly depraved. Politicians had become demagogues; the concentration of power and increase of immorality proceeded equally. The Roman power included one hundred and twenty millions of people. Wealth was the only standard of social distinction. Law was of no value; the suitor was compelled to deposit a bribe before a trial could be had. Draper in his intellectual development of Europe says of this period of Roman history: The social fabric was a festering mass of rottenness. The people had become a populace; the aristocracy was demoniac; the city was a hell. No crime that the annals of human wickedness can show was left unperpetrated—remorseless murders; the betrayal of parents, husbands, wives and friends. Poisoning was reduced to a system; adultery degenerated into incest, and crimes that cannot be written. Women of the higher class were so depraved, lascivious and dangerous, that men could not be compelled to contract matrimony with them; marriage was displaced by concubinage; even virgins were guilty of inconceivable immodesties; great officers of state and ladies of the court of promiscuous bathings and naked exhibitions. In the time of Caesar it had become necessary for the government to put a premium on marriage. He gave rewards to women who had many children; prohibited those women under forty-five years of age and having no children, from wearing jewels and riding in litters, hoping by such social distinctions to correct the evil. It went from bad to worse, so that Augustus in view of the general avoidance of legal marriage, and resort to concubinage with slaves, was compelled to impose penalties on the unmarried—to exact that they should not inherit by will except from relations.The Roman women reckoned the years not from the consuls but from the men they had lived with. Gluttony was carried to loathsomeness. It was said of them—they eat that they may vomit, and vomit that they may eat. At the taking of Perusium, three hundred of the most distinguished citizens were solemnly sacrificed at the altar of Divius Julius by Octavius. Moral principle was extinct, it was a nation of atheists. Religious sentiment was entirely effaced. It was skeptical thought that governed the minds of the scholars; Varro, one hundred and ten years B. C, said that the gods were to be received as mere emblems of the forces of matter. Lucretius recommends that the mind be emancipated from the fear of the gods; Cicero was a skeptic. Some thought a virtuous life should be lived; some were cynics, some stoics. Epictetus (55-135 A.D), the slave and philosopher, taught that suicide was man's privilege. Seneca (4 B.C.-65 A.D.) said that time is our only possession, and that nothing else belonged to man. And we may well understand the influence all this must have had on the medical doctrines of the physicians of that time.

Bradford then posed the question: "What effect had Christianity on medicine?" His answer:

Rutherford Russell says that it is likely that Christianity must at first have acted injuriously on medicine. Jesus Christ was celebrated as a healer; he went about healing the sick and restoring to life. To the people of his time his principal occupation was the healing of the sick. This power possessed by the Saviour was given by him to his disciples. Luke had been a physician; but how could he prescribe after the manner of men, when he was able to heal by the grace of God? Thus medicine based as an art on the natural order of things, was for a time superseded by the preternatural power of certain men. But between religion and science there was a barrier great and unsurmountable.

So while Christianity did help to improve the plight of the poor, it did so (at least initially) by taking away from the aristocracy the gift of wisdom from the Greeks. It would be another thousand years before wisdom would come back to the civilized world, and another 1700 years before a system was created to encourage common folks to use their wisdom to improve medicine for all the masses.

References:

1. Bradford, Thomas Lindsley, writer, Robert Ray Roth, editor, “Quiz questions on the history of medicine from the lectures of Thomas Lindley Bradford M.D.,” 1898, Philadelphia, Hohn Joseph McVey

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400-1743: The first use of the term influenza

In the ancient world all diseases were attributed to the wrath of the "diety." If a Pandemic ravaged a village, town or nation, it was attributed to an angry god or spirit.  Both the ancient Greek poet Homer (800-701) and Hippocrates (460-370) described pandemics during their lifetimes.  It's probable some of these were attributed to the influenza virus.

Homer describes how Zeus used his thunderbolt to "punish impiety," and "for vengeance for an insult offered to his priest, the shafts of the Sun-god carried sickness into the Argive camp, destroying first the dogs and mules, and then thousands of warriors," writes Arthur Hopkirk, in his 1914 book "Influenza."  (1, page vii and viii)

In reality these warriors may have died of a pandemic caused by a virus or bacteria, such as influenza.  Although the ancients had no clue about the internal workings of the human body, nor about invisible invaders of the human body.  It was easier for them to believe in fake gods and attribute them when bad things like plagues happened.

"On mules and dogs th' infection first began;

And last, the vengeful arrows fix'd in man."

Those described as having sweats and chills (signs of a fever) were the most likely to succumb to the disease.  In man's desire to help his fellow man, the following were the remedies tried (1, page 15-16):

• Purging
• Venesection
• Bleeding by the ranal vein
• Emetics

And sometimes the remedy wreaked more havoc than the plague.  If ruthless venesection was performed, this in and of itself could have been the killer.  Yet the plague was blamed nonetheless.

The plague struck again and again.  In 412 B.C. the following was written regarding a plague in Rome (1, page 16):

“A plague, however, which broke out at that time and gave more alarm than it proved destructive, diverted the people’s attention from the forum and political disputes to look after their families and take care of their health. The city was all over oppressed with sickness, though no great mortality ensued.”

It struck again (or so historians think) in (1, page 20-26)...

• 827 A.D. in France and Germany
• 876 in Italy
• 889 in Germany
• 927 in France and Germany
• 996-97 in England
• 1173 in Germany and Italy (it was called "a dense fog" in Italy, first authentic outbreak)
• 1239
• 1311
• 1323 in Italy and France
• 1327-28
• 1357
• 1287 in France and Germany
• 1403 in Paris, France
• 1404
• 1410-11 in France
• 1413-14 in France
• 1427 in France caused a "Poisonous air."
• 1438
• 1482
• 1505
• 1510

The following quote comes from 1323 (3):  

In the year, 1323, and in the month of August, there was a pestilential wind, which caused nearly all the inhabitants of Florence to fall sick of cold and fever, and the same thing took place throughout almost of whole of Italy.

And the following from 1327 (3):

In the said year and month, there was throughout the whole of Italy an infection fever caused by cold; but few people died of it.

Regarding the 1387 outbreak, the following was written (4):

There came a general pestilence in the whole country, with cough and influenza, so that hardly one among ten remained healthy. 

Regarding the 1427 outbreak, an anonymous chronicler from St. Albans wrote (1, page 25-6):

In the beginning of October, a certain rheumy infirmity which is called 'mure' invaded the whole people, and so infected the aged along with the younger, that it conducted a great number to the grave. 

The remedy for the 1387 pandemic, which took few lives, was "decoctions of chamomile and coriander berries, sweetened with syrup and poppies; clymasta; diaphoretics; and low diet." (1, page 23)  This would have been a more pleasant remedy compared to what the ancient Greeks treated the symptoms.  

Many of the deaths that resulted occurred on the fifth or sixth day, and Hippocrates notes that death usually occurred on the seventh day.  Later, in the first century A.D., Galen agreed with Hippocrates that death usually occurred on the seventh day.  (1, page 17)

At some point in our history, sometime in the ancient world, the concept that little creatures in the air may be responsible for spreading some diseases was postulated, although who postulated this theory, and when, remains a mystery.

Hopkirk says the first to write of this concept may have been the Greek "polyhistorian" Varro (117-36 B.C.), who wrote the following:

It is to be observed that wherever there are marshy districts certain most minute animals will grow, which cannot be discerned by the eye; but, carried by the air, reach the body through the mouth and nostrils, causing serious disease." (1, page x)

Varro was referring to the malaria plague in "Corfu when Pompey was there with an army and fleet."  Although the same concept may be applied to other contagious diseases, such as influenza.  Varro recommended the following to prevent the spread of the disease malaria: (1, page x)

• Isolation
• Ventilation
• Destruction of insanitary dwellings
• Etc.

Influenza is known to cause much grief for those afflicted with it, although it causes only a few deaths.  Usually those who die from it are over the age of 65 or have some chronic underlying medical condition that is complicated by influenza.

Prior to the 16th century influenza was referred to by various names, depending on the geographic region of the person describing it.  Sometimes it was simply referred to as a pest, pestilence, or plague.  Historians determine if the "plague" was influenza by descriptions of the symptoms, a high morbidity, yet low mortality rate.  If many deaths resulted, chances are that particular plague was not influenza. (1, page 4-5)

The term influenza may actually have come from a misinterpretation of the Italian word influence.  The idea here is that around 1357 people believed the position of the stars "influenced" outbreaks of the disease.  Although how this term superseded all the other terms and made it's way into medical nomenclature remains a mystery.  (1, page 6)(2, page 31)

The following are just a few other names used to describe various pandemics or endemics most historians figure were influenza (1, pages 8-9):

1. Burzelen:  1307 in Germany (meaning to stumble?)
2. Le tac or le horion:  1411 in France
3. Tonawasches Fieber:  1414 in Germany (Because occurred in Danube district)
4. Coqueluche: 1414 in France (Caused oppressive pain in the head)(Victims wore cap on head)
5. Ladendo:  1427 in France
6. Schafkrankheit or Schafhusten:  1580 in Germany (Sheep's disease, cough)
7. Galanteriekrankheit or Modefieber: 1709 in Germany (Galant malady, fashionable fever)
8. Le Grippe:  1743 in France (from "agripper," meaning to sieze quickly and cause sore throat
9. Petite poste or petite courrier:  1762 in France
10. Zamporina:  Brazil in 1780
11. La Coquette:  France 1780-81
12. Russische Krankheit (lightning catarrh):  1782 in Germany (due to its sudden onset)
13. Corcunda (hunchback disease):  Brazil in 1816.  Violent cough made you hunch your back
14. Polka Fever:  1846-7 in Brazil

In Great Britain during the 14th and 15th centuries, common names were faucht and slaodan.  Creatan was a word derived from creat (chest), and was another common name.  In 1562 it was called "the newe acquayntance.  In 1580 "the gentle correction."  It was also referred to as "the jolly rant," "the new delight," "the Dunkirk rant," and "the knock-me-down fever." (1, page 9)

An outbreak in Britain in 1485 was described as "English Sweat." It was so back that "King Henry VII had to postpone his coronation," according to Evelyn Kelly and Claire Wilson in their 2011 book "Investigating Influenza and Bird Flu."  "The disease was treated with tobacco juice, lime juice, and bloodletting." (2, page 32)

Finally, in 1743, the term influenza was used to describe influenza.  No one knows why, but this is the term that stuck, and has since made it's way to medical nomenclature.  The only exception was in Germany, where the Grippe was the term commonly used as of 1743.  

While the names varied through early history, the "grip" the disease held on it's victims were similar:

• Catarrh:  Inflammation of the respiratory tract (nasal congestion)
• Fever:  Usually over 100 degrees
• Chills:  Associated with the fever
• Headache:
• Body or muscle aches: Especially of the back, arms and legs
• Dry cough: Helps spread the disease from one victim to the next
• Fatigue and weakness:  General feeling of tiredness
• Suspended Business: Many stopped working to take care of their families

It's generally the commonality of symptoms described, the high rate of morbidity, and low mortality, that has allowed historians to feel confidence these epidemics and pandemics were probably influenza.  

References:

1. Hopkirk, Arthur F., "Influenza: It's History, Nature, Cause and Treatment," 1914, New York, Charles Scribner and Sons
2. Kelly, Evelyn B., PhD and Claire Wilson, "Investigating influenza and Bird Flu: Real facts and real lives," 2011, Enslow Publishers, U.S., Chapter 2, "The History of Influenza," pages 29-47
3. Hopkirk, op cit,Gluge, "in the course of his argument, quotes the following passages from Buoninsegni’s Istoria Fiorentina, Florence, 1580." The passages are recorded on page 21 of Hopkirk's book.  
4. Hopkirk, op cit, from Jakob von Konigshoven Stassburg Chronicles, of 1387, as recorded by Hopkirk on page 22 of his book

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400 B.C.-200 A.D.: A history of 'vital air'

Air has existed since the beginning of our existence, that we know for sure.  Without air we wouldn't have life, and people must have figured that out at an early date.  They also must have figured out early that breathing is necessary for life, considering when people stop breathing life ends.  (7, page 473)

Primitive people and ancient societies didn't know about air, let alone about oxygen. However, as far back as 1000 B.C., ancient Hindu physicians who wrote the Charaka and Sustrata recognized both the presence of the lungs and the 'prana vayu,' a substance in the air that many historians believe was oxygen. (5)

"Charaka (500 B.C.) mentions the head, the chest, the ears, the tongue, the mouth and the nose as the seat of 'prana vayu.'  Sustrata (1000 B.C) spoke of 'prana vayu' as flowing in the mouth. What else can this 'prana vayu' be identified with," said S.K. Jindal in his 2008 book, "Oxygen Therapy." (5)

Anaximenes of Miletus (585-525 B.C.) believed that air "was the primary principle," and he referred to is at the pneuma, or "the breath of life," said William Henry Osler, the father of modern medicine. He said the "pneuma was described by Anaximens as the "psychic force that animates the body and leaves it at death -- 'our soul being air, holds us together'" (9, pages 38-39)

Yet it was Empedocles (490-430 B.C.), a pre-Socratic Greek philosopher, who first conceived the idea that air contained a substance that was vital to life. He defined air as one of the four basic elements: air, water, earth and fire. Everything that we see is made up of these substances, and health of animals and humans was determined by the equilibrium of these four substances. (9, page 40)

He was also the first to describe respiration:

"As soon as that humidity, of which there is a great store on the first formation of the foetus, begins to be diminished, the air insinuating itself through the pores of the body succeeds it; after this the natural heat, by its tendency to make its escape, drives the air out, and when this natural heat enters the body again the air follows it afresh. The former of these actions is called Inspiration, and the latter Expiration."  (1, page 47-48)

He described how with the inspiration air entered into the body, and that it was circulated through the body by the "continuous motion" of the blood, and that it nourishes the heart and the mind.  Empedocles explains that the heart "nourished in the sea of blood which courses in two opposite directions: this is the lace where is found for the most part when men call Thought; for the blood round the heart is Thought in mankind." (2, page 186)

He also may have been the first to observe of the "faetus in utero" that "respiration commenced before birth."

Aristotle (384-322 B.C.), a Greek philospher and student of Plato (and teacher to Alexander the Great), mentioned "air" as one of the essential elements of life.  He observed that air had weight when he wrote that "a bladder filled with air was heavier than an empty bladder." (6, page 19)

He did not know that there was a difference between arteries and veins, although he did know that both were filled with blood. He also knew that the heart was the key to "circulation" of the vital spirit.  He actually came up with the term vessels as he noted the vessels contained the blood as in a vase. The lungs inhaled the spirits and pneuma from the air from the trachea (which he referred to as the arteria, because it contained air. Hippocrates also referred to the trachea as the arteria. (9, page 72)

Praxagoras of Athens (born 340 B.C.) believed that "pulsation was only in the arteries, and maintained that only the veins contained blood, and the arteries air," writes William Henry Osler.  "As a rule the arteries are empty after death, and Praxagoras believed that they were filled with an aeriform fluid, a sort of pneuma, which was responsible for their pulsation."  He was among the first to study the pulse. (9, page 72)

Archimides (287-212 B.C.), a Greek mathemetician and stronomer, wrote that "air is weighed in air." (6, page 19)

In the 3rd century B.C., Erasistratos (335-280 B.C.) of the School of Alexandria, in Egypt, recognized the relationship between air and blood and that air was essential for life to exist.Around 294 B.C. Erasistratos "taught that arteries carried blood to the various parts of the body; those vessels carried air and air only, and the blood was carried in the other vessels, the veins."  (7, page 473)

He also believed the heart contained no blood (8, page 94)  In fact, Osler explains, it's for this reason arteries got their name, as the term "artery" comes from the Greek term arteria, or air.  The trachea was referred to as the windpipe, or arteria tracheia, also known as "the rough air tube." (9, page 72)

Erasistratos contested that air contained a substance (a pneuma) that, once it entered the body, it was transformed into this "vital pneuma" that was essential for life.  This transformation was performed in the "left ventricle of the heart and, together with blood, results in heat, energy, and life.... a part of the vital pneuma enters the brain where it turns into 'psychic pneuma.'  This psychic pneuma processes sensory perceptions and renders possible understanding and knowledge."  (3, page 8)

Osler adds that this "vital pneuma"  was also the cause of the heart beat, "the source of innate heat of the body, and it maintained the processes of digestion and nutrition." It's sent to the brain where an animal spirit is formed, and this spirit is sent to the nerves of the body to give the person emotion and sensation and motion. Osler explains that when we use the terms "high spirits" and "low spirits," these terms come from the views of Erasistratos and other ancient Greek philosophers.  (9, page 73)

By 70-160 A.D. Athenaeus of Cicilia opened what was called the "pneumatic school" of medicine that "flourished" for many years.  The pneumatic theory held that there was a pneuma in the air that was inhaled, transported to the heart by vessels, and then transported to the rest of the body by vessels.  This pneuma was therefore essential for good health and life, for maintaining a balance of the four humors by maintaining an appropriate level of heat and moisture. (2, page 291)

Aretaeus of Cappadocia (130-200 A.D.), a physician from ancient Greece, believed the heart was "the exciting cause or principle of respiration," according to Hamilton, "being seated in the centre of the lungs, which it inspires with a desire for fresh air. The lungs he did not believe to be susceptible of pain, from being composed of a loose sort of substance like wool; rough cartilaginous arteries, according to him, were dispersed throughout them; they were unprovided with muscles, and furnished only with some small and slender nerves, by means of which their motion was produced." (1, page 32)

Middle Ages diagram of Galen's concept of blood flow

Aelius Galen (130-200 A.D.), a famous Greco-Roman physician, studied the heart extensively  Osler notes that he "studied particularly the movements of the heart, the actions of the valves, and the pulsatile forces in the arteries.  He observed venous blood was darker, and believed it provided nutrition to the body. Arterial blood was thinner and brighter, and this was because it contained an abundance of "vital spirit," or vital air.  Arterial blood was warmed in the left ventricle, and this heat was sent to all the organs of the body.(9, page 80).

Galen also observed, as did Erasistratus, that the veins and arteries communicate by small pores and small vessels that allows for the mingling of spirits and blood. He did not, however, know the blood circulated, as he though it made it's way to the organs by small pores. However, some historians, including Osler, believe he was very close to figuring this out, and if given more time he probably would have. He did not see the heart as a pump, but as a fireplace, notes Osler. (9, page 80)

He believed the purpose of the heart was to warm the blood.  He believed the left ventricle purified the blood and sent pure blood to the vital organs, such as the liver.  (7, page 473)

It should also be known that, according to Phillip Crampton in his 1839 "Outlines of the history of medicine, nothing remains of the writings of Erasistratos, so much of what we know about his anatomical discoveries comes from the writings of Galen. Crampton said that Galen described Galen's view of the passage of blood and air through the body this way:

According to him, the air passes from the lungs to the heart, which performs the functions of a smith's bellows, attracting the air by the dilatation of the left auricle ; from the left auricle it passes by the arteries which contain air, or rather animal spirits, to every part of the body. The veins contain all the blood, and according to this supposition, fever and inflammation are the consequence of any portion of blood passing, by an error loci, from the veins into the arteries. (10, page 519)

Galen supported this view and added to it.  Crampton explains it was Galen who was perhaps the first to describe human respiration:

Some notion of the state of experimental philosophy in the time of Galen, may be formed from the account which he gives of the experiment by which he Convinced the assembled physicians and philosophers of Rome, that air was contained within the cavity of the chest, between the lungs and the pleura costalis; he says he explained to them the manner in which the air passed from the lungs through the cribriform plate of the sethmoid bone into the ventricles of the brain, in which a true respiration was performed, the organ rising and falling in correspondence with the motions of the chest, and the air escaping through the sutures and the palate (10, page 520)

So Galen supported the views of Erasistratos and then expanded upon them. He agreed with Erasistratus that some pneuma in the air was inhaled, warmed in the heart, and sent to the body by a series of vessels and cannals and pores.  He also believed something of waste was exhaled.  He actually proved by experiments Erisistratos wrong when he asserted the arteries contained air not blood.  Galen proved arteries contained blood.  (7, page 473)(9, page 82)

Arthur John Brock, in the introduction of his 1916 translation of some of Galen's works, explains Galen's thoughts on how blood and air flowed through the body:

In his opinion, the great bulk of the blood travelled with a to-and-fro motion in the veins, while a little of it, mixed with inspired air, moved in the same way along the arteries; whereas we now know that all the blood goes outward by the arteries and returns by the veins; in either case blood is carried to the tissues by blood-vessels, and Galen's ideas of tissuenutrition were wonderfully sound. (10, page xxxvi)

He also explained that the "spongy flesh of the lungs acts upon the air we inhale converting it to a subtler product, pneuma.  This refined breath passes through very find 'pores' into branches of the pulmonary vein, and thence is 'attracted,' with blood, by the attractive faculty into the left ventricle of the heart, where it encounters more hot blood and becomes metamorphosed into life giving, i.e. 'vital' pneuma." As the pneuma is 'transported' to the various parts of the body it is further metamophosed.  (4, page 45)

Why were there two sets of vessels for the same fluid? Galen wondered.  And he speculated, as historian William Hamilton notes that:

the great vein (vena cava) was the great reservoir of the blood, while the aorta was the recipient of the spirits, and that, notwithstanding the proximity of the mouths of the veins and arteries to each other, the blood, during the continuance of health, did not enter the vessels in which the spirits flow; but, when this arrangement happens to be disturbed by any violence, that the blood forces its way into the arteries, and occasions more or less disorder of the system. The only use which he assigned to the process of respiration was to supply the arteries with air (what he referred to as vital air).

Yet this is all just speculation, and there were many theories as to what this 'vital air' contained.  Regardless, Galen was so well respected by the medical community that his theory grabbed a hold and held a prominent position in the minds of physicians for the next 1,900 years.  This theory held strong even when better wisdom became available.

References:

1. Hamilton, William, "A History of Medicine, Surgery and Anatomy," 1831, Vol. I, London, New Burlington
2.  Prioreschi, Plinio, "A History of Medicine: Greek Medicine," Vol. II, 1994, 2004, 2nd ed., NE,  Horatius Press
3. Tesak, Juergen, Chris Code, "The History of Aphasia: Theories and Protagonists," 2008, New York, Psychology Press
4. Wilson, Nigel, "Encyclopedia of Ancient Greece," 2006, NY, Taylor and Francis
5. Jindel, S.K.,Ritesh Agarwal, "Oxygen Therapy," 2009,2nd ed., Jaypee Brothers, pages 5-8
6. Tissier, page 19
7. Hill, Leonard, "Recent Advances in Physiology and bio-chemistry," 1908, London, Edward Arnold
8. Garrison, Fielding H, "An introduction to the history of medicine," 3rd edition, 1922, Philadelphia and London, W.B. Saunders Company, page 95
9. Osler, William, "The Evolution of Modern Medicine: A series of lectures at Yale University on the Silliman Foundation in April, 1913," New Have, Yale University Press, 1921,
10. Crampton, Phillip, "Outlines of the history of medicine from the earliest historic period to the present time, intended to illustrate the connextion between the progress of anatomy and the improvements of the healing arts," read before the Royal College of Surgeons on November 29, 1838, published in The Dublin Journal of Medical Science, 1839, Volume 14, Dublin, Published by Hodges and Smith, pages 504-533
11. Galen, writer, Arthur John Brock, translator, "Galen: On the Natural Faculties," 1916, London and New York, William Hienemann and G.P. Putnam's Sons

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124-200 A.D.: Roman physicians describe tracheotomies

Knowledg of mouth to mouth breathing and the operation of tracheotomy was carried from ancient Greece to ancient Rome by the physician Asclepiades of Bythinia. (124-40 B.C.).

Prior to Asclepiades the Romans had a negative view of the harsh medicine of the Greeks, although Asclepiades was able to convince the Romans that Greek medicine could be useful for saving lives and soothing the minds of the sick.

Once again I quote Renouard:

Asclepiades of Bythinia, had the idea of opening a passage for the air, by making an incission into the larynx or trachea; but the authors who report this fact do not describe the operation he adopted. After him, no one dared attempt tracheotomy until Antyllus, who practiced it several times, and described his mode of operating.  (1, pages 448-449)

Antyllus, a Greek physician who lived in Rome sometime between the birth of Jesus and the 4th century (and probably in the 2nd century), had a fragment of his writings preserved by Paulus Aegineta (625-690), some of which provides one of our first accounts of the surgical procedure:  

"The incision should be made in the trachea, under the larynx, about the third or fourth ring. This situation is most eligible, because it is not covered by any muscles, and no vessels are near it. The patient's head must be kept back, in order that the trachea may project more forward. A transverse cut is to be made between two of the rings, so as not to wound the cartilage, only the membrane." (2)(3)(also see 5, page 521)

The GrecoRoman physician Galen (120-200 A.D.) stated that Aesculapius (around 100 A.D.) was the first to recommend tracheotomy, so we may speculate Galen also used it.   Both Aeretaeus (130-200 A.D) and Caelius-Aurelianus (5th century) mention the recommendation by Aesculapius, although Aeretaeus condemned the procedure out of fear the cartilage would not heal, and Caelius talked of it as a rash procedure never put into practice.  (2)(5, page 521)

Galen also described tracheostomies, and described inflating lungs with bellows through a hole in the trachea.  (4) 

Chances are Galen performed his experiments on animals, probably pigs, dogs or apes.  Yet even if he never performed it on a human, his efforts may have been the first mechanical breaths. 

So, like ancient Greek physicains, ancient Roman physicians were knowledgeable of the operation of tracheotomy, and performed experiments that would be picked up by later physicians who would have had better knowledge of anatomy.   

References:

1. Lee, W.L., A.S. Stutsky, "Ventilator-induced lung injury and recommendations for mechanical ventilation of patients with ARDS," Semin. Respit. Critical Care Medicine, 2001, June, 22, 3, pages 269-280
2. Fourgeaud, V.J, "Medicine Among the Arabs," (Historical Sketches), Pacific medical and surgical journal, Vol. VII, ed. V.J. Fourgeaud and J.F. Morse, 1864, San Fransisco, Thompson & Company,  pages 193-203  (referenced to page 198-9)
3. "Biographical Dictionary of the society for the diffusion of useful knowledge," Longman, Brown, Green and Longmans, volume III, 1843, A. Spottingwood, London, page 124-5
4. Szmuk, Peter, eet al, "A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age," Intensive Care Medicine, 2008, 34, pages 222-228
5. Mackenzie, Morrell, "Diseases of the throat and nose, Volume I, 1880, Philadelphia, Presley Blakiston

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800-400 B.C.: Greeks define tracheotomy

Knowledge of mouth to mouth breathing and the surgical procedure of tracheotomy would have made it's way from ancient Egypt to ancient Greece. There were many Greek philosophers who studied medicine at one of Egypts fine schools, probably at Heliopolis early on and Alexandria later. The procedure more than likely made it's way to Greece by this means. 

So this knowledge must have appeared via a dream to a priest at the Asclepion at Cos, who must have used it successfully at some point early in Greek's history. Details of the procedure and the diagnosis it was used for would have been surreptitiously etched onto a stone slab that was kept at the temple for future reference. The slabs may also have been used as early medical texts, as such temples also served as schools. 

Sometime around 450 B.C. a boy by the name of Hippocrates (460-370 B.C.) sat with his father, a physician, at the temple, learning as much as he could about medicine, perhaps using the stone slabs as texts. Hippocrates grew to become the greatest physician of the ancient world, and would become the first to write about the procedure in his Hippocratic Corpuus.  He wrote:

"A tube should be inserted into the throat, along the jaws, so that the air may be attracted to the lungs."  (1) 

The procedure is perhaps best detailed by historian Pierre Victor Renouard in his 1867 history of medicine:

When the air passage is stopped by any obstacle, the anguish is extreme, the suffocation iminent, and the patient speedily dies, unless promptly succored. This accident has sometimes occurred in a violent quinsey, but more frequently in the fibrinous effusion in children, called croup. The Hippocratic works indicate as the only resource in this extremity, to pass a leek leaf, or any elastic tube, into the throat of the patient; but this agent is very diflicult of application, and I doubt whether it was ever done advantageously.(2, pages 448-449)

The ancient Greeks would have referred to this procedure as a tracheotomy.  The term, according to dictionary.com, comes from a combination of the Greek terms for "windpipe" (arterios trakheia) and "to cut into" (tom).  It means to cut into the trachea.

Another term, tracheostomy, comes from the combination of the Greek terms for "windpipe" (arterios trakheia) and "mouth, opening, or orifice" (stoma).  It is the creation of an opening in the trachea.  The opening is often referred to as a stoma, which comes from the Greek term for mouth, opening, orifice.  It is the opening created in the trachea or, simply, the hole in the trachea.

However, it should be understood here that, according to Dr. Morrell Mackenzie in his 1880 book "Disease of the nose and throat," the term tracheotomy was first used by Lorenz Heister (1683-1758).  Prior to him the procedure was actually called a bronchotomy.  Mackenzie defined bronchotomy as "the various operations by which the air-passages are laid open."  (3, pages 520,522)

For simplicities sake, I will simply refer to the procedure as a tracheotomy for the purposes of this history.

So while the ancient Greeks definitely didn't invent the procedure, they gave it a name and an identity.

References:

1. Fourgeaud, V.J, "Medicine Among the Arabs," (Historical Sketches), Pacific medical and surgical journal, Vol. VII, ed. V.J. Fourgeaud and J.F. Morse, 1864, San Fransisco, Thompson & Company, pages 193-203 (referenced to page 198-9) 
2. Lee, W.L., A.S. Stutsky, "Ventilator-induced lung injury and recommendations for mechanical ventilation of patients with ARDS," Semin. Respit. Critical Care Medicine, 2001, June, 22, 3, pages 269-280 
3. Mackenzie, Morrell, "Diseases of the throat and nose, Volume I, 1880, Philadelphia, Presley Blakiston

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870 B.C.: The first description of artificial resuscitation

Elijah resuscitating a child 

Similar to other ancient civilizations, the Jews believed life and death, and health and sickness, were the result of the desires of their God, the Lord. Likewise, in the rare cases when a person was believed to be dead and then brought back to life, this was due to the wishes of their God, the Lord.

No one knows what they called it, although by the 18th century it was referred to as reanimation, and by the mid 20th century it was referred to as resuscitation. Both terms work equally well, as animate comes from the Latin term anamatus which comes from anima, meaning "to give life to" or to breathe. It may also come from the Greed word anemos for wind. Likewise, suscitate is a Latin term for "to stir up or rouse." (1)

The first description of an animation or a suscitation was when, through Adam, God created Eve: 

Adam was all alone in the garden with no one to help him. So, God put Adam into a deep sleep and took one of his ribs and formed it into a woman to be Adam's wife. Adam named her "Eve."

The work of the Lord could also be done through a prophet.  The Lord God had many prophets over the years covered in the Bible, among the first was a prophet named Elijah.  He is believed to have lived in the Northern Kingdom of Israel sometimes around 870 or 850 B.C.  

He is described as performing many miracles through the assistance of the Lord. In the First Book of Kings he is described as resuscitating (or reanimating). A Sidonian widow woman was taking care of him during a drought when her son fell ill and became apparently dead. She approached Elijah with the body of her son: 

Some time later the son of the woman who owned the house became ill. He grew worse and worse, and finally stopped breathing. She said to Elijah, “What do you have against me, man of God? Did you come to remind me of my sin and kill my son?”

“Give me your son,” Elijah replied. He took him from her arms, carried him to the upper room where he was staying, and laid him on his bed. Then he cried out to the Lord, “Lord my God, have you brought tragedy even on this widow I am staying with, by causing her son to die?” Then he stretched himself out on the boy three times and cried out to the Lord, “Lord my God, let this boy’s life return to him!”

The Lord heard Elijah’s cry, and the boy’s life returned to him, and he lived. Elijah picked up the child and carried him down from the room into the house. He gave him to his mother and said, “Look, your son is alive!”

Then the woman said to Elijah, “Now I know that you are a man of God and that the word of the Lord from your mouth is the truth.” (Kings 1: 17-24)

The Sidonian widow at first appears to be angry at Elijah and his God for allowing her child to become sick and to die. Perhaps she doubts Elijah because she is a Sidonian widow and not an Israelite. Once the miracle is performed, she no longer has any doubts that he is a prophet of the Lord, and that he is a healer.

Elijah "stretched himself out on the boy three times." Why is this such a vague description? It was perhaps because the authors of the Bible were not concerned with what Elijah did, as all the Jewish people needed to know about medicine was that the Lord brings sickness and health. By obeying the Lord, the Lord will heal. By disobeying the Lord, the Lord will not heal. That's all people needed to know.

They did not need to know that Elijah was educated in all the wisdom of the land. They did not need to know that among his education involved knowledge of physics, chemistry, philosophy, mathematics, and medicine. They did not need to know that the procedure he performed on the boy was a method of artificial resuscitation. What he did, the method he used, was only eluded to because it did not matter. 

References:

1. Definitions come from merriam-webster.com,  http://www.merriam-webster.com/dictionary/animate and http://www.merriam-webster.com/dictionary/suscitate, accessed 9/26/2013

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400 B.C.: Hippocrates alludes to heart failure

I wanted to make a note here that Hippocrates had no way of knowing about heart failure, or any other diseases of the heart.  So, when the heart caused dyspnea, this would simply be diagnosed as asthma.

However, Hippocrates, and other Greek physicians, did recognize and diagnose as diseases some of the symptoms of heart failure, such as angina (chest pain), dropsy (swelling of the feet and ankles, and hydropsy (fluid in the lungs) and anascara (generalized edema).

In his book "On the Different Parts of Man, Hippocrates said:

Angina arises from blood arrested in the vessels of the neck. (1, page 243)

Here he must have recognized that many people who present with chest pain also have bulging carotid arteries, or the arteries on either side of the neck.   He would have no way of associating this with heart failure.

He continued:

We must bleed in the arm and purge, to divert downward the humours that cause the disease. (1, page 243)

In his book "On Internal Affections," described dropsy, which was the diagnosis when fluid was observed inside the tissue, and he referred to a condition where the fluid caused swelling of various tissues of the body, such as in the feet and ankles, as anascara.

In his book "Predictions and Prognostics," he said that dropsy, like phthisis and epilepsy, are difficult to cure when congenital.  He said: (1, page 129)

For the cure of dropsy, sound viscera and adequate strength, with good digestion, are very essential; good breathing, freedom from pain, equable temperature of the whole body, no emaciation of the limbs, but rather a fulness, although the absence of both is best, with natural softness and size, and the belly soft to the touch. There should be neither cough, thirst, nor dry tongue, whether after sleep, or at other times, as often is the case. The appetite should be good, and after eating no uneasiness. Purgatives should operate promptly, and at other times the stools should be soft and figured. The urine should correspond with the regimen, and with the changes of wines. Labour should be readily supported without feeling fatigued. Such is the best state for an hydropic person, to give the expectation of recovery. In proportion as it deviates therefrom are our hopes to be less sanguine; but they must entirely cease when the reverse of what is above stated is the actual condition; or only be maintained according to the existing state of things.

It is much to be feared that dropsy will succeed large discharges of blood from the stomach and bowels; when connected with fever it will be of a brief character, and few recover. A prediction to this effect may be safely made to the friends of the patient. Large oedematous swellings, disappearing, and recurring again, are more readily cured than in the preceding case. (1, page 129)

Interestingly, he also said:

They are (the symptoms), however  very deceptive, inducing the patient to dismiss his physician, and thus dying without assistance. (1, page 129)

Dropsy of the lung, or fluid in the lung, was treated similar to hydrothorax, with an incision of the chest between ribs to drain fluid from the lung.  (1, page 261)

So he recognized the fact that people suffering from this ailment often did not recognize the symptoms and seek medical attention until it was too late.  This is a common predicament of modern medicine as well.

In "Rationale of Food in Acute Disease: Book IV," he recommends pleurisy, angina and dropsy all be treated with cantharides and other acrids. The patient must also pay close attention to diet, and vomit three times a day for a month. (1, page 221)

In "Semeiotics III: On the Difference of Pulses," Galen said that Hippocrates was the first to use the term "palpitate" as when feeling for a pulse, and "palpitations," as when feeling an abnormal, or rapid beating of the heart. (1, page 602)

The medical profession would not even begin to understand the heart and heart diseases, such as angina and heart failure, until after great minds like Vesalius and Harvey made their great discoveries in the 16th and 17th centuries.

References:

1. Hippocrates, Claudius Galen, writers,  John Redman Coxe, 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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400 B.C.: Hippocrates describes pneumothorax

While he didn't understand it nor its cause, Hippocrates described a condition that we now refer to as pleural effusion and he referred to as hydrothorax.  It's a condition where fluid builds up in the pleural cavity.

As a remedy, he described the procedure of paracentesis, which involved creating an incision above the third false rib, and inserting a tube into the opening. He then used a trocar.  A Trocar, according to dictionary.com, is a sharp pointed instrument enclosed in a cannula that was used for withdrawing fluid from the cavity. (1, page 282)

This procedure was very similar to the procedure physicians would perform today for the same ailment. The main difference is that modern physicians would know about aseptic technique and would be better capable of controlling pain.

References:

1. Hippocrates, Claudius Galen, writers,  John Redman Coxe, 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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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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