THE GREAT SCOURGE
Not only have most diseases a living cause, and a consequent natural
history and course, but they have a special method of attack, which
looks almost like a preference. It seems little wonder that the
terror-stricken imagination of our Stone Age ancestors should have
personified them as demons, "attacking" or leaping upon their victims
and "seizing" them with malevolent delight. The concrete comparison was
ready to their hand in the attack of fierce beasts of prey; and as the
tiger leaps for the head to break the neck with one stroke of his paw,
the wildcat flies at the face, the wolf springs for the slack of the
flank or the hamstring, so these different disease demons appear each to
have its favorite point of attack: smallpox, the skin; cholera, the
bowels; the Black Death, the armpits and the groin; and pneumonia, the
lung.
There are probably few diseases which are so clearly recognized by every
one and about which popular impressions are in the main so clear-cut and
so correct as pneumonia. The stabbing pain in the chest, the cough, the
rusty or blood-stained expectoration, the rapid breathing, all stamp it
unmistakably as a disease of the lung. Its furious onset with a
teeth-chattering chill, followed by a high fever and flushed face, and
its rapid course toward recovery or death, mark it off sharply from all
other lung infections.
Its popular names of "lung fever," "lung plague," "congestion of the
lungs," are as graphic and distinctive as anything that medical science
has invented. In fact, our most universally accepted term for it,
pneumonia, is merely the Greek equivalent of the first of these.
It is remarkable how many of our disease-enemies appear to have a
preference for the lung as a point of attack. In the language of _Old
Man Means_ in "The Hoosier Schoolmaster," the lung is "their fav'rit
holt." Our deadliest diseases are lung diseases, headed by consumption,
seconded by pneumonia, and followed by bronchitis, asthma, etc.;
together, they manage to account for one-fourth to one-third of all the
deaths that occur in a community, young or old. No other great organ or
system of the body is responsible for more than half such a mortality.
Now this bad eminence has long been a puzzle, since, foul as is the air
or irritating as is the gas or dust that we may breathe into our lungs,
they cannot compare for a moment with the awful concoctions in the shape
of food which are loaded into our stomachs. Even from the point of view
of infections, food is at least as likely to be contaminated with
disease-germs as air is. Yet there is no disease or combination of
diseases of the whole food canal which has half the mortality of
consumption alone, in civilized communities, while in the Orient the
pneumonic form of the plague is a greater scourge than cholera.
It has even been suggested that there may possibly be a historic or
ancestral reason for this weakness to attack, and one dating clear back
to the days of the mud-fish. It is pointed out that the lung is the last
of our great organs to develop, inasmuch as over half of our family tree
is under water. When our mud-loving ancestor, the lung-fish (who was
probably "one of three brothers" who came over in the Mayflower--the
records have not been kept) began to crawl out on the tide-flats, he had
every organ that he needed for land-life in excellent working condition
and a fair degree of complexity: brain, stomach, heart, liver, kidneys;
but he had to manufacture a lung, which he proceeded to do out of an old
swim-bladder. This, of course, was several years ago. But the lung has
not quite caught up yet. The two or three million year lead of the other
organs was too much to be overcome all at once. So carelessly and
hastily was this impromptu lung rigged up that it was allowed to open
from the front of the gullet or [oe]sophagus, instead of the back, while
the upper part of the mouth was cut off for its intake tube, as we have
already seen in considering adenoids, thus making every mouthful
swallowed cut right across the air-passages, which had to be provided
with a special valve-trap (the epiglottis) to prevent food from falling
into the lungs.
So, whenever you choke at table, you have a right to call down a
benediction upon the soul of your long departed ancestor, the lung-fish.
However applicable or remote we may regard "the bearin's of this
observation," the practical and most undesirable fact confronts us
to-day that this crossing and mutual interference of the air and the
food-passages is a fertile cause of pneumonia, inasmuch as the germs of
this disease have their habitat in the mouth, and are from that
lurking-place probably inhaled into the lung, as is also the case with
the germs of several milder bronchitic and catarrhal affections.
It may be also pointed out that, history apart, our lung-cells at the
present day are at another disadvantage as compared with all the other
cells of the body, except those of the skin; and that is, that they are
in constant contact with air, instead of being submerged in water.
Ninety-five per cent of our body-cells are still aquatic in their
habits, and marine at that, and can live only saturated with, and bathed
in, warm saline solution. Dry them, or even half-dry them, and they die.
Even the pavement-cells coating our skin surfaces are practically dead
before they reach the air, and are shed off daily in showers.
We speak of ourselves as "land animals," but it is only our lungs that
are really so. All the rest of the body is still made up of sea
creatures. It is little wonder that our lungs should pay the heaviest
penalty of our change from the warm and equable sea water to the gusty
and changeable air.
Even if we have set down the lung as a point of the least resistance in
the body, we have by no means thereby explained its diseases. Our point
of view has distinctly shifted in this respect within recent years.
Twenty years ago pathologists were practically content with tracing a
case of illness or death to an inflammation or disease of some
particular organ, like the heart, the kidney, the lung, or the stomach.
Now, however, we are coming to see that not only may the causation of
this heart disease, kidney disease, lung disease, have lain somewhere
entirely outside of the heart, kidney, or lung, but that, as a rule, the
entire body is affected by the disease, which simply expresses itself
more violently, focuses, as it were, in this particular organ. In other
words, diseases of definite organs are most commonly the local
expressions of general diseases or infections; and this local
aggravation of the disease would never have occurred if the general
resisting power and vigor of the entire body had not been depressed
below par. So that even in guarding against or curing a disease of a
particular organ it is necessary to consider and to treat the whole
body.
Nowhere is this new attitude better illustrated than in pneumonia. Frank
and unquestioned infection as it is, wreaking two-thirds of its visible
damage in the lung itself, the liability to its occurrence and the
outlook for its cure depend almost wholly upon the general vigor and
rallying power of the entire body. It is perfectly idle to endeavor to
avoid it by measures directed toward the protection of the lung or of
the air-passages, and equally futile to attempt to arrest its course by
treatment directed to the lung, or even the chest. The best place to
wear a chest-protector is on the soles of the feet, and poulticing the
chest for pneumonia is about as effective as shampooing the scalp for
brain-fag.
This clears the ground of a good many ancient misconceptions; for
instance, that the chief cause of pneumonia is direct exposure to cold
or a wetting, or the inhalation of raw, cold air. Few beliefs were more
firmly fixed in the popular mind--and, for the matter of that, in the
medical--up to fifteen or twenty years ago. It has found its way into
literature; and the hero of the shipwreck in an icy gale or of weeks of
wandering in the Frozen North, who must be offered up for artistic
reasons as a sacrifice to the plot, invariably dies a victim of
pneumonia, from his "frightful exposure," just as the victim of
disappointed love dies of "a broken heart," or the man who sees the
ambitions of years come crashing about his ears, or the woman who has
lost all that makes life worth living, invariably develops "brain
fever."
There is a physical basis for all of these standard catastrophes, but it
is much slenderer than is usually supposed. For instance, almost every
one can tell you how friends of theirs have "brought on congestion of
the lungs," or pneumonia, by going without an overcoat on a winter day,
or breaking through the ice when skating, or even by getting their feet
wet and not changing their stockings; and this single dramatic instance
has firmly convinced them that the chief cause of "lung fever" is a
chill or a wetting. Yet when we come to tabulate long series of causes,
rising into thousands, we find that the percentage in which even the
patients themselves attribute the disease to exposure, or a chill, sinks
to a surprisingly small amount. For instance, in the largest series
collected with this point in mind, that of Musser and Norris, out of
forty-two hundred cases only seventeen per cent gave a history of
exposure and "catching cold"; and the smaller series range from ten to
fifteen per cent. So that, even in the face of the returns, not more
than one-fifth of all cases of pneumonia can reasonably be attributed to
chill. And when we further remember that under this heading of exposure
and "catching cold" are included many mere coincidences and the chilly
sensations attending the beginning of those milder infections which we
term "common colds," it is probable that even this small percentage
could be reduced one-half. Indeed, most cautious investigators of the
question have expressed themselves to this effect. This harmonizes with
a number of obstinate facts which have long proved stumbling-blocks in
the way of the theory of exposure as a cause of pneumonia. One of the
classic ones was that, during Napoleon's frightful retreat from Moscow
in the dead of winter, while his wretched soldiers died by thousands of
frost-bite and starvation, exceedingly little pneumonia developed among
them. Another was that, as we have already seen with colds, instead of
being commoner and more frequent in the extreme Northern climate and on
the borders of the Arctic Zone, pneumonia is almost unknown there. Of
course, given the presence of the germ, prolonged exposure to cold may
depress the vital powers sufficiently to permit an attack to develop.
Again, the ages at which pneumonia is both most common and most deadly,
namely, under five and over sixty-five, are precisely those at which
this feature of exposure to the weather plays the most insignificant
part. Last and most conclusive of all, since definite statistics have
begun to be kept upon a large scale, pneumonia has been found to be
emphatically a disease of cities, instead of country districts. Even
under the favorable conditions existing in the United States, for
instance, the death-rate per hundred thousand living, according to the
last census, was in the cities two hundred and thirty-three, and for the
country districts one hundred and thirty-five,--in other words, nearly
seventy per cent greater in city populations.
How, then, did the impression become so widely spread and so firmly
rooted that pneumonia is chiefly due to exposure? Two things, I think,
will explain most of this. One is, that the disease is most common in
the winter-time, the other, that like all febrile diseases it most
frequently begins with sensations of chilliness, varying all the way
from a light shiver to a violent chill, or _rigor_. The savage,
bone-freezing, teeth-rattling chill which ushers in an attack of
pneumonia is one of the most striking characteristics of the disease,
and occurs in twenty-five to fifty per cent of all cases.
Its chief occurrence in the winter-time is an equally well-known and
undisputed fact, and it has been for centuries set down in medical works
as one of the diseases chiefly due to changes in temperature, humidity,
and directions of the wind. Years of research have been expended in
order to trace the relations between the different factors in the
weather and the occurrence of pneumonia, and volumes, yes, whole
libraries, published, pointing out how each one of these factors, the
temperature, humidity, direction of wind, barometric pressure, and
electric tension, is in succession the principal cause of the spread of
this plague. Many interesting coincidences were shown. But one thing
always puzzled us, and that was, that the heaviest mortality usually
occurred, not just at the beginning of winter, when the shock of the
cold would be severest, nor even in the months of lowest temperature,
like December or January, but in the late winter and the early spring.
Throughout the greater part of the temperate zone the death-rate for
pneumonia begins to rise in December, increases in January, goes higher
still in February, reaching its climax in that month or in March. April
is almost as bad, and the decline often doesn't fairly set in until May.
No better illustration could probably be given of the danger of drawing
conclusions when you are not in possession of all the facts. One thing
was entirely overlooked in all this speculation until about twenty years
ago,--that pneumonia was due not simply to the depressing effects of
cold, but to a specific germ, the pneumococcus of Fraenkel. This threw
an entirely new light upon our elaborate weather-causation theories. And
while these still hold the field by weight of authority and that mental
inertia which we term conservatism, yet the more thoughtful physicians
and pathologists are now coming to regard these factors as chiefly
important according to the extent to which we are crowded together in
often badly lighted and ill-ventilated houses and rooms, with the
windows and doors shut to save fuel, thus affording a magnificent
hothouse hatching-ground for such germs as may be present, and ideal
facilities for their communication from one victim to another. At the
same time, by this crowding and the cutting off of life and exercise in
the open air which accompanies it, the resisting power of our bodies is
lowered. And when these two processes have had an opportunity of
progressing side by side for from two to three months; when, in other
words, the soil has been carefully prepared, the seed sown, and the
moist heat applied as in a forcing-house, then we suddenly reap the
harvest. In other words, the heavy crop of pneumonia in January,
February, and March is the logical result of the seed-sowing and forcing
of the preceding two or three months.
The warmth of summer is even more depressing in its immediate effects
than the cold of winter, but the heat carries with it one blessing, in
that it drives us, willy-nilly, into the open air, day and night. And on
looking at statistics we find precisely what might have been expected on
this theory, that the death-rate for pneumonia is lowest in July and
August.
It might be said in passing that, in spite of our vivid dread of
sunstroke, of cholera, and of pestilence in hot weather, the hot months
of the year in temperate climates are invariably the months of fewest
diseases and fewest deaths. Our extraordinary dread of the summer heat
has but slender rational physical basis. It may be but a subconscious
after-vibration in our brain cells from the simoons, the choleras, and
the pestilences of our tropical origin as a race. Open air, whether hot,
cold, wet, dry, windy, or still, is our best friend, and house air our
deadliest enemy.
If this view be well founded, then the advance of modern civilization
would tend to furnish a more and more favorable soil for the spread of
this disease. This, unfortunately, is about the conclusion to which we
are being most unwillingly driven. Almost every other known infectious
disease is diminishing, both in frequency and in fatality, under
civilization. Pneumonia alone defies our onslaughts. In fact, if
statistics are to be taken at their surface-value, we are facing the
appalling situation of an apparently marked increase both in its
prevalence and in its mortality. For a number of years past, ever since,
in fact, accurate statistics began to be kept, pneumonia has been listed
as the second heaviest cause of death, its only superior being
tuberculosis.
About ten years ago it began to be noticed that the second competitor in
the race of death was overtaking its leader, and this ghastly rivalry
continued until about three years ago pneumonia forged ahead. In some
great American cities it now occupies the bad eminence of the most fatal
single disease on the death-lists.
The situation is, however, far from being as serious and alarming as it
might appear, simply from this bald statement of statistics. First of
all, because the forging ahead of pneumonia has been due in greater
degree to the falling behind of tuberculosis than to any actual advance
on its part. The death-rate of tuberculosis within the last thirty years
has diminished between thirty and forty per cent; and pneumonia at its
worst has never yet equaled the old fatality of tuberculosis.
Furthermore, all who have carefully studied the subject are convinced
that much of this apparent increase is due to more accurate and careful
diagnosis. Up to ten years or so ago it was generally believed that
pneumonia was rare in young children. Now, however, that we make the
diagnosis with a microscope, we discover that a large percentage of the
cases of capillary bronchitis, broncho-pneumonia, and acute congestion
of the lung in children are due to the presence of the pneumococcus.
Similarly, at the other end of the line, deaths that were put down to
bronchitis, asthma, heart failure, yes, even to old age, have now been
shown on bacteriological examination to be due to this ubiquitous imp of
malevolence; so that, on the whole, all that we are probably justified
in saying is that pneumonia is not decreasing under civilization. This
is not to be wondered at, inasmuch as the inevitable crowding and
congestion which accompanies civilization, especially in its derivative
sense of "citification," tends to foster it in every way, both by
multiplying the opportunities for infection and lowering the resisting
power of the crowded masses.
Moreover, it was only in the last ten years, yes, within the last five
years, that we fairly grasped the real method and nature of the spread
of the disease, and recognized the means that must be adopted against
it. And as all of these factors are matters which are not only
absolutely within our own control, but are included in that programme of
general betterment of human comfort and vigor to which the truest
intelligence and philanthropy of the nation are now being directed, the
outlook for the future, instead of being gloomy, is distinctly
encouraging.
Our chief difficulty in discovering the cause of pneumonia lay in the
swarm of applicants for the honor. Almost every self-respecting
bacteriologist seemed to think it his duty to discover at least one, and
the abundance and variety of germs constantly or accidentally present in
the human saliva made it so difficult positively to isolate the real
criminal that, although it was identified and described as long ago as
1884 by Fraenkel, the validity of its claim was not generally recognized
and established until nearly ten years later.
It is a tiny, inoffensive-looking little organism, of an oval or
lance-head shape, which, after masquerading under as many aliases as a
confidence man, has finally come to be called the pneumococcus, for
short, or "lung germ." Though by those who are more precise it is still
known as the _Diplococcus pneumoniæ_ or _Diplococcus lanceolatus_, from
its faculty of usually appearing in pairs, and from its lance-like
shape. Its conduct abounds in "ways that are dark and tricks that are
vain," whose elucidation throws a flood of light upon a number of
interesting problems in the spread of disease.
First of all, it literally fulfills the prognostic of Scripture, that "a
man's foes shall be they of his own household," for its chosen abiding
place and normal habitat is no less intimate a place than the human
mouth. Outside of this warm and sheltering fold it perishes quickly, as
cold, sunlight, and dryness are alike fatal to it.
We could hardly believe the evidence of our senses when studies of the
saliva of perfectly healthy individuals showed this deadly little
bacillus to be present in considerable numbers in from fifteen to
forty-five per cent of the cases examined. Why, then, does not every one
develop pneumonia? The answer to this strikes the keynote of our modern
knowledge of infectious disease, namely, that while an invading germ is
necessary, a certain breaking down of the body defenses and a lowering
of the vital resistance are equally necessary. These invaders lie in
wait at the very gates of the citadel, below the muzzles of our guns, as
it were, waiting for some slackening of discipline or of watchfulness to
rush in and put the fortress to sack. Nowhere is this more strikingly
true than in pneumonia. It is emphatically a disease where, in the
language of the brilliant pathologist-philosopher Moxon, "While it is
most important to know what kind of a disease the patient has got, it is
even more important to know what kind of a patient the disease has got."
The death-rate in pneumonia is an almost mathematically accurate
deduction from the age, vigor, and nutrition of the patient attacked. No
other disease has such a brutal and inveterate habit of killing the
weaklings. The half-stifled baby in the tenement, the underfed,
overworked laboring man, the old man with rigid arteries and stiffening
muscles or waning life vigor, the chronic sufferer from malnutrition,
alcoholism, Bright's disease, heart disease--_these_ are its chosen
victims.
Another interesting feature about the pneumococcus is its vitality
outside of the body. If the saliva in which it is contained be kept
moist, and not exposed to the direct sunlight and in a fairly warm place,
it may survive as long as two weeks. If dried, but kept in the dark, it
will survive four hours. If exposed to sunlight, or even diffuse
daylight, it dies within an hour. In other words, under the conditions
of dampness and darkness which often prevail in crowded tenements it may
remain alive and malignant for weeks; in decently lighted and ventilated
rooms, less than two hours. This explains why, in private practice and
under civilized conditions, epidemics of this admittedly infectious
disease are rare; while in jails, overcrowded barracks, prison ships,
and winter camps of armies in the field they are by no means uncommon.
This is vividly supported by the fact brought out in our later
investigations of the sputum of slum-dwellers, carried out by city
boards of health, that the percentage of individuals harboring the
pneumococcus steadily increases all through the winter months, from ten
per cent in December to forty-five, fifty, and even sixty per cent in
February and March. The old proverb, "When want comes in at the door,
Love flies out at the window," might be revised to read, "When sunlight
comes in at the window the pneumococcus flies 'up the flue.'"
Authorities are still divided as to the meaning and even the precise
frequency of the occurrence of the pneumococcus in the healthy human
mouth. Some hold that its presence is due to recent infection which has
either been unable to gain entrance to the system or is preparing its
attack; others, that it is a survival from some previous mild attack of
the disease, and the body tissues having acquired immunity against it,
it remains in them as a harmless parasite, as is now well known to be
the case with the germs of several of our infectious diseases--for
instance, typhoid--for months and even years afterward. Others hold the
highly suggestive view that it is a normal inhabitant of the healthy
mouth, which can become injurious to the body, or _pathogenic_, only
under certain depressed or disturbed conditions of the latter. In
defense of this last it may be pointed out that dental bacteriologists
have now already isolated and described some thirty different forms of
organisms which inhabit the mouth and teeth; and the pneumococcus may
well be one of these. Further, that a number of our most dangerous
disease germs, like the typhoid bacillus, the bacillus of tuberculosis,
and the bacillus of diphtheria, have almost perfect "doubles,"
law-abiding relatives, so to speak, among the germs that normally
inhabit our throats, our intestines, or our immediate surroundings. The
ultimate foundation question of the science of bacteriology is, How did
the disease germs become disease germs? But the question is still
unanswered.
However, fortunately, here, as in other human affairs, imperfect as our
knowledge is, it is sufficient to serve as a guide for practical
conduct. Widely present as the pneumococcus is, we know well that it is
powerless for harm except in unhealthful surroundings. There is another
interesting feature of its life history which is of practical
importance, and that is, like many other bacilli it is increased in
virulence and infectiousness by passing through the body of a patient.
Flushed with victory over a weakened subject, it acquires courage to
attack a stronger. This is the reason why, in those comparatively
infrequent instances in which pneumonia runs through a family, it is the
strongest and most vigorous members of the family who are the last to be
attacked. It also explains one of the paradoxes of this disease, that,
while emphatically a disease of overcrowding and foul air, and attacking
chiefly weakened individuals, it is a veritable scourge of camps,
whether mining or military. When once three or four cases of pneumonia
have occurred in a mining camp, even though this consist almost
exclusively of vigorous men, most of them in the prime of life, it
acquires a virulence like that of a pestilence, so that, while
ordinarily not more than fifteen to twenty per cent of those attacked
die, death-rates of forty, fifty, and even seventy per cent are by no
means uncommon in mining camps. The fury and swiftness of this "miners'
pneumonia" is equally incredible. Strong, vigorous men are taken with a
chill while working in their sluicing ditches, are delirious before
night, and die within forty-eight hours. So widely known are these
facts, and so dreaded is the disease throughout the Far West and in
mountain regions generally, that there is a widespread belief that
pneumonia at high altitudes is particularly deadly.
I had occasion to interest myself in this question some years ago, and
by writing to colleagues practicing at high elevations and collecting
reports from the literature, especially of the surgeons of army posts in
mountain regions, was somewhat surprised to find that the mortality of
all cases occurring above five thousand feet elevation was almost
identical with that of a similar class of the population at sea-level.
It is only when a sufficient number of cases occur in succession to
raise the virulence of the pneumococcus in this curious manner that an
epidemic with high fatality develops.
That this increase in virulence in the organism does occur was clearly
demonstrated by a bacteriologist friend of mine, who succeeded in
securing some of the sputum from a fatal case in the famous Tonopah
epidemic of some years ago, an epidemic so fatal that it was locally
known as the "Black Death." Upon injecting cultures from this sputum
into guinea-pigs, the latter died in one-quarter of the time that it
usually took them to succumb to a similar dose of an ordinary culture of
the pneumococcus.
It is therefore evident that just as "no chain is stronger than its
weakest link," so in the broad sense no community is stronger than its
weakest group of individuals, and pneumonia, like other epidemics, may
be well described as the vengeance which the "submerged tenth" may wreak
from time to time upon their more fortunate brethren.
Now that we know that under decent and civilized conditions of light and
ventilation the pneumococcus will live but an hour to an hour and a
half, this reduces the risk of direct infection under these conditions
to a minimum. It is obvious that the principal factors in the control of
the disease are those which tend to build up the vigor and resisting
power of all possible victims. The more broadly we study the disease the
more clearly do the data point in this direction.
First of all, is the vivid and striking contrast between hospital
statistics and those gathered from private practice. While many
individuals of a fair wage-earner's income and good bodily vigor are
treated in our hospitals, yet the vast majority of hospital patients are
technically known as the "hospital classes," apt to be both underfed,
overworked, and overcrowded. On the other hand, while a great many both
of the very poor and even of the destitute are treated in private
practice, yet the majority of such cases who feel "able to afford a
doctor," as they say, are among the comparatively vigorous, well-fed,
and well-housed section of the community. And the difference between the
death-rate of the two classes in pneumonia is most significant. In
private practice, while epidemics differ in virulence, the rate ranges
all the way from five per cent to fifteen per cent, the average being
not much in excess of ten per cent, occasionally falling as low as three
per cent. In the hospital reports on the contrary the death-rate begins
at twenty per cent and climbs to thirty, forty, and forty-five per cent.
It is only fair to say, of course, that hospital statistics probably
include a larger percentage of more serious cases, the milder ones being
taken care of at home, or not presenting themselves for treatment at
all. But even when this allowance has been made, the contrast is
convincing.
A similar influence is exercised by age. Although pneumonia is common at
all ages, its heaviest death-rate falls at the two extremes, under six
years of age and over sixty, with a strong preponderance in the latter.
Under five years of age, the mortality may reach twenty to thirty per
cent; from five to twenty-five, not more than four to five per cent;
from twenty-five to thirty-five, from fifteen to twenty per cent; and so
on, increasing gradually with every decade until by sixty years of age
the mortality has reached fifty per cent, and from sixty to seventy-five
may be expressed in terms of the age of the patient. One consoling
feature, however, about it is that its mortality is lowest in the ages
at which it is most frequent, namely, from ten to thirty-five years of
age. And its frequency diminishes even more rapidly than its fatality
increases in later years. So that while it is much more serious in a
middle-aged man, he is less liable to develop it than a younger one.
Where the mortality from pneumonia is highest, is in the most densely
populated wards, especially among negroes and foreigners of the hospital
class, in individuals who are victims of chronic alcoholism, and also
among those who are for long periods insufficiently nourished. Lastly,
it is only within comparatively recent years that we have come clearly
to recognize the large rôle which pneumonia plays in giving the
finishing stroke to chronic diseases and degenerative processes. It is,
for instance, one of the commonest actual causes of death in Bright's
disease, in diabetes, in lingering forms of tuberculosis, and in heart
disease; and last of all, in that progressive process of normal
degeneration and decay which we term "Old Age." It is one of the most
frequent and fatal of what Flexner described a decade ago as "terminal
infections." Very few human beings die by a gradual process of decay,
still less go to pieces all at once, like the immortal "One-Hoss Shay."
Just as soon as the process has progressed far enough to lower the
resisting power below a certain level, some acute infection steps in and
mercifully ends the scene. This is peculiarly true of pneumonia in old
age.
To the medical profession to "die of old age" is practically equivalent
to dying of pneumonia. The disease is so mild in its symptoms and so
rapid in its course that it often utterly escapes recognition as such.
The old man complains of a little pain in his chest, a failure of
appetite, a sense of weakness and dizziness. He takes to his bed, within
forty-eight hours he becomes unconscious, and within twenty-four more he
is peacefully breathing his last. After death, two-thirds of the lung
will be found consolidated. So mild and rapid and painless is the
process that one physician-philosopher actually described pneumonia as
"the friend of old age."
When once the disease has obtained a foothold in the body its course,
like one of Napoleon's campaigns, is short, sharp, and decisive.
Beginning typically with a vigorous chill, sometimes so suddenly as to
wake the patient out of a sound sleep, followed by a stabbing pain in
the side, cough, high fever, rapid respiration, the sputum rusty or
orange-colored from leakage of blood from the congested lung, within
forty-eight hours the attacked area of the lung has become congested; in
forty-eight more, almost solidified by the thick, sticky exudate poured
out from the blood-vessels, which coagulates and clots in the air cells.
So complete is this solidification that sections of the attacked lung,
instead of floating in water as normal lung-tissue will, sink promptly.
The severe pain usually subsides soon, but the fever, rapid respiration,
flushed face, with or without delirium, will continue for from three to
seven or eight days. Then, as suddenly as the initial attack, comes a
plunge down of the temperature to normal. Pain and restlessness
disappear, the respiration drops from thirty-five or forty to fifteen or
twenty per minute, and the disease has practically ended by "_crisis_."
Naturally, after such a furious onslaught, the patient is apt to be
greatly weakened. He may have lost twenty or thirty pounds in the week
of the fever, and from one to three weeks more in bed may be necessary
for him to regain his strength. But the chief risk and danger are
usually over within a week or ten days at the outside.
Violent and serious as are the changes in the lung, it is very seldom
that death comes by interference with the breathing space. In fact,
while regarded as a lung disease, we are now coming to recognize that
the actual cause of death in fatal cases is the overwhelming of the
heart by the toxins or poisons poured into the circulation from the
affected lung. The mode of treatment is, therefore, to support the
strength of the patient in every way, and measures directed to the
affected lung are assuming less and less importance in our arsenal of
remedies. Our attitude is now very similar to that in typhoid, to
support the strength of the patient by judicious and liberal feeding, to
reduce the fever and tone up his blood-vessels by cool sponging,
packing, and even bathing; to relieve his pain by the mildest possible
doses of sedatives, knowing that the disease is self-limited, and that
in patients in comfortable surroundings and fair nutrition from eighty
to ninety per cent will throw off the attack within a week. So
completely have we abandoned all idea of medicating or protecting the
lung as such, that in place of overheated rooms, loaded with vapor by
means of a steam kettle, for its supposed soothing effect upon the
inflamed lung, we now throw the windows wide open. And some of our more
enthusiastic clinicians of wide experience are actually introducing the
open-air cure, which has worked such wonders in tuberculosis, in the
treatment of pneumonia. In more than one of our New York hospitals now,
particularly those devoted to the care of children, following the
brilliant example of Dr. William Northrup, wards are established for
pneumonia cases out on the roof of the hospital, even when the snow is
banked up on either side, and the covering is a canvas tent. Nurses,
physicians, and ward attendants are clothed in fur coats and gloves, the
patients are kept muffled up to the ears, with only the face exposed;
but instead of perishing from exposure, little, gasping, struggling
tots, whose cases were regarded as practically hopeless in the wards
below, often fall into the sleep that is the turning point toward
recovery within a few hours after being placed in this winter
roof-garden.
In short, our motto may be said to be, "Take care of the patient, and
the disease will take care of itself."
Though pneumonia is one of our most serious and most fatal of diseases,
yet it is one over whose cause, spread, and cure we are obtaining
greater and greater control every day, and which certainly should,
within the next decade, yield to our attack, as tuberculosis and typhoid
are already beginning to do.