Part 9 (1/2)

CHAPTER VIII

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 ca.n.a.l 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-pa.s.sages, 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-pa.s.sages 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 s.h.i.+fted 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 att.i.tude better ill.u.s.trated 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-pa.s.sages, 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-f.a.g.

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 s.h.i.+pwreck 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 cras.h.i.+ng 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 cla.s.sic 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 s.h.i.+ver 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 princ.i.p.al 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 ill.u.s.tration 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, w.i.l.l.y-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 pa.s.sing 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 diminis.h.i.+ng, 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 compet.i.tor 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.