Preventable Diseases

by Woods Hutchinson

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.