Part 10 (1/2)
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 s.p.a.ce. 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 a.s.suming less and less importance in our a.r.s.enal of remedies. Our att.i.tude 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 m.u.f.fled up to the ears, with only the face exposed; but instead of peris.h.i.+ng 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.
CHAPTER IX
THE NATURAL HISTORY OF TYPHOID FEVER
Why should not a disease have a natural history, as well as an individual? At first sight, this might appear like a reversion to the old, crude theory of disease as a demonic obsession, or invasion by an evil spirit, of which traces still remain in such expressions as, ”She was _seized_ with a convulsion,” ”He was strong enough to _throw off_ the illness,” ”He was _attacked_ by a fever,” etc. But apart entirely from such conceptions, which were perfectly natural in the infancy of the race, while clearly recognizing that disease is simply a perverted state of nutrition or well-being in the body of the patient, a disturbance of balance, so to say, yet it is equally true that it has a birth, an ancestry, a life-course, and a natural termination, or death.
This recognition of the natural causation and development of disease has been one of the greatest triumphs, not merely of pathology, but of intelligence and rationalism. It has done more to diminish that dread of the unknown which hangs like a black pall of terror over the mind of the savage and the semi-civilized mind than any other one advance. It contributes enormously to our courage, our hopefulness, and our power of protection in more ways than one: first of all, by revealing to us the external cause of disease, usually some careless, dirty, or bad habit on the part of an individual or of the community, and thus enabling us to limit its spread and even exterminate it; secondly, by a.s.suring us that nearly all diseases, excepting a few of the most obstinate and serious, have not only a definite beginning, but a definite end, are, in fact, if left to themselves, self-limited, either by the exhaustion and loss of virulence of their cause, or by the resisting power of the body.
All infectious diseases, and many others, tend to run a definite course of so many days, or so many weeks, within certain limits, and at least ninety per cent of them tend to terminate in recovery. It is a most serious and fatal disease which has a death-rate of more than twenty per cent. Typhoid, pneumonia, diphtheria, and yellow fever all fall below this, smallpox barely reaches it, and only the bubonic plague, cholera, and lockjaw rise habitually above it. The recognition of this fact has enormously increased the efficiency of the medical profession in dealing with disease, by putting us on the track of imitating the methods which the body itself uses for destroying, or checking the spread of, invading germs and leading us to trust nature and try to work with her instead of against her. Our ant.i.toxins and anti-serums, which are our brightest hope in therapeutics at present, are simply antidotes which are formed in the blood of some healthy, vigorous animal against the bacillus whose virulence we wish to neutralize, such as that of diphtheria or septicemia.
Diphtheria ant.i.toxin, for instance, the first and best known triumph of the new medicine, is the antidotal substance formed in the blood of a horse in response to a succession of increasing doses of the bacilli of diphtheria. Similar antidotal substances are formed in the blood in all other non-fatal cases of infectious diseases, such as typhoid, pneumonia, blood-poisoning, etc.; and the point at which they have acc.u.mulated in sufficient amounts to neutralize the poison of the invading germs, forms the crisis, or ”turn” of the disease. So that when we speak of a disease ”running its course,” we mean continuing for such length of time as the body needs to produce anti-bodies in sufficient amounts to check it.
The princ.i.p.al obstacle to the securing of ant.i.toxins like that of diphtheria for all our infectious diseases is, that their germs form their poison so slowly that it is difficult to collect it in sufficient amounts to produce a strong concentrated ant.i.toxin in the animal into which it is injected. But the overcoming of this difficulty is probably only a question of time.
Obviously, if infectious disease be, as we say, ”self-limited,” that is to say, if the body will defeat the invaders with its own weapons, on an average in nine cases out of ten, our wisest course, as physicians, is to back up the body in its fight. This we now do in every possible way, by careful feeding, by rest, by bathing, by an abundance of pure water and fresh air, with the gratifying result that we have already reduced the death-rate in most fevers, even such as we have no ant.i.toxin against, or may not even have discovered the causal germ of, to one-half and even three-fourths of their former fatality. The recognition of the fact that disease has a natural history, a birth, a term of natural life and a death, has already turned a hopeless fight in the dark into a victorious campaign in broad daylight. Huxley's pessimistic saying that typhoid was like a fight in the dark between the disease and the patient, and the doctor like a man with a club striking into the melee, sometimes. .h.i.tting the disease and sometimes the patient, is no longer true since the birth of bacteriology.
Nowhere can the natural history of disease be more clearly seen or more advantageously studied than in the case of typhoid fever.
The cause of typhoid is simplicity itself, merely drinking the excreta of some one else, ”eating dirt,” in the popular phrase; simple, but of a deadly effectiveness, and disgracefully common. The demon may be exorcised by an incantation of one sentence: _Keep human excreta out of the drinking water._ This sounds simple, but it is n't. Eternal vigilance is the price of health as well as of liberty.
We can, however, make our pedigree of typhoid a little more precise. It is not merely dirt of human origin which is injurious, but dirt of a particular type, namely, discharges from a previous case of the disease.
Just as in the fight against malaria we have not the enormous problem of the extermination of all varieties of mosquito, but only of one particular genus, and only the infected specimens of that, so in typhoid, the contamination of water or food which we have to guard against is that from previous cases. From one point of view, this leaves the problem as wide as ever, for, obviously, the only way to insure against poisoning of water by typhoid discharges is to shut out absolutely all sewage contamination. On the other hand, it is of immense advantage in this regard,--it enables us to fight the enemy at both ends of the line, to turn his flank as well as crush his centre.
While we are protecting our water-supplies against sewage, we can, in the meantime, render that sewage comparatively harmless by thoroughly disinfecting and sterilizing all discharges from every known case of the disease. A similar method is used in the fight against yellow fever and malaria. Not only are the breeding places of the two mosquito criminals broken up, but each known case of the disease is carefully screened, _so as to prevent the insects from becoming infected_, and thus able to transmit the disease to other human victims.
It cannot be too emphatically insisted upon that every case of typhoid, like every case of yellow fever and of malaria, _comes from a previous case_. It is neither healthy nor exhilarating to drink a clear solution of sewage, no matter how dilute; but, as a matter of fact, it is astonis.h.i.+ng how long communities may drink sewage-laden water with comparative impunity, so long as the sewage contains no typhoid discharges. One case of typhoid fever imported into a watershed will set a city in a blaze.
The malevolent _Deus_ in the sewage _machina_ is, of course, a germ--the _Bacillus typhosus_ of Eberth. The astonis.h.i.+ng recentness of much of our most important knowledge is nowhere better ill.u.s.trated than in the case of typhoid. Although there had been vague descriptions of a fatal fever, slow and lingering in its character and accompanied by prolonged stupor and delirium, which was a.s.sociated with camps and dirty cities and famines, from as far back as the age of Caesar, the first description clear enough to be recognizable was that of Willis, of an epidemic during the English civil war in 1643, both Royalist and Roundhead armies being seriously crippled by it. Since that time a smouldering, slowly spreading fever has been pretty constantly a.s.sociated with armies in camps, besieged cities, filthy jails, and famines, to which accordingly have been given the names, familiar in historical literature, of ”famine fever,” ”jail fever,” and ”military fever.”
So slowly, however, did accurate knowledge come, that it was actually not until 1837 that it was clearly and definitely recognized that this famine fever was, like Mrs. Malaprop's Cerberus, ”two gentlemen at once,” one form of it being typhus or ”spotted fever,” which has now become almost extinct in civilized communities; the other, the milder, but more persistent form, which, like the poor, we have always with us, called, from its resemblance to the former, ”typhoid” (typhus-like).
Typhus was a far more virulent, rapid, and fatal fever than its twin survivor, though as to the relations between the two diseases, if any, we are quite in the dark, as the former practically disappeared before the days of bacteriology. The fact of its disappearance is both significant and interesting, in that it was unquestionably due to the ranker and viler forms of both munic.i.p.al and individual filthiness and unsanitariness, which even our moderate progress in civilization has now abolished. There can be no question that, with a step higher in the scale of cleanliness, and further quickening of the biologic conscience, typhoid will also disappear.
Typhus, the bubonic plague, the sweating sickness, were alike plagues and products of times when table-sc.r.a.ps were thrown on the dining-room floor and covered daily with fresh rushes for a week at a stretch, and fertilizer acc.u.mulated in a living-room as now in a modern stable.
Clothing was put on for the season, s.h.i.+rts were unknown, and strong perfumes took the place of a bath. Michelet's famous characterization of the Middle Ages in one phrase as _Un mille ans sans bain_ (a thousand years without a bath) was painfully accurate.
Doubtless certain habits of our own to-day will be regarded with equal disgust by our descendants. Typhus, by the way, may possibly be remembered by the dramatic ”Black a.s.size” of Oxford, in 1577, in which not merely the wretched prisoners in the jail, but the jurors, the lawyers, the judges, and every official of the court were attacked, and many of them died.