White Coat Underground

Captain of the men of death

I have in front of me a weathered copy of Cecil’s Textbook of Medicine from 1947. It belonged to my father, who graduated from medical school in the 1940s. Even then, it was known that pneumoccus, a common bacterium, can live harmlessly in the nose and throat and only sometimes causes disease. Pneumoccocal disease was and is still a leading cause of disease and death*, killing perhaps a million children per year. It causes ear and sinus infections, but also meningitis, and is the most common cause of pneumonia. In the past it was referred to as “the captain of the men of death” for it’s ability to claim so many. It is also closely associated with influenza—the pneumococcus that may live harmlessly in the mouth may find the damaged lung of the flu patient a nice place to set up shop. The pneumonia that follows an influenza infection can be devastating and preventing it is an important public health goal.

The bacteria itself has been known for over a century, when it was discovered by US Army doctor George Sternberg in a frontier post in 1881. A couple of decades later, sera were developed to fight the disease. There were no antibiotics at the beginning of the 20th century, and as influenza killed millions, often of pneumonia, scientists were were working feverishly (and often dying) trying to save lives. They discovered some of the most important serotypes of pneumococcus, created serum from horses, and injected it into sick patients with significant good results.

The discovery of antibiotics significantly changed the pneumonia landscape. According to Cecil:

The role of pneumococcal infections as a cause of death has been amazingly diminished by the introduction of sulfonamide and penicillin therapy.

A fascinating report in the journal Chest was published in 1943 and described the treatment of pneumonia with sulfonamides in the Panama Canal Zone.  The mortality rate for treated patients with confirmed pneumococcal disease was 1%, something unheard of until then.

But in these early days of antibiotics, the course of the disease was still described in nearly Hippocratic terms. From Cecil again:

Pneumonia may terminate by crisis or lysis. The typical crisis of pneumonia is one of the most striking features of the disease. The patient, struggling against a virulent infection, often appears on the verge of collapse. The whole organism seems to be affected by the toxemia. Suddenly the patient begins to perspire freely; there is a rapid drop in temperature to normal or subnormal, accompanied by a corresponding fall in the respiratory and pulse rate. In a few hours the entire clinical picture is changed. The patient looks and feels much better and drops off into a quiet sleep…

In many cases there is no definite crises, but the patient’s temperature comes down gradually by lysis…

He goes on to describe the course when there is no crisis or lysis—death by sepsis, although he doesn’t use that word.

Today, even with antibiotics, pneumoccal diseases remain an important cause of illness and death.  But we have another weapon: vaccination.  

Pneumoccal vaccines have been around for a long time, and the current vaccine protects against 23 strains accounting for about 90% of pneumococcal disease.  The vaccine does not prevent all pneumococcal disease, but it does prevent the most complications.  

The New York Times is now reporting that pneumoccal vaccination has the potential to prevent complications and death during the current pandemic.  It should be old news, but the CDC is reporting a spike in cases, especially in young people.  Pneumococcal vaccination, which is recommended for those over 65 is also recommended for many groups of young people, including smokers.  Improving pneumococcal vaccine rates in recommended populations has a real potential to save lives during this pandemic and during subsequent flu seasons.  With flu vaccines being sporadically available, pneumococcal vaccines, which are widely available, can help save lives.  I don’t think Cecil would have been surprised, but he certainly would have been pleased.  

References

Cecil, Russell L. A Textbook of Medicine. Saunders, 1947.

Barry, John M. The Great Influenza. Viking, 2004.

Browne SM, Marvin HP, and Smith ER.  Sulfadiazine pneumonia therapy in the canal zone.  Chest, 1943;9;297-301.

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*According to the CDC:

Each year in the United States, there are an estimated 175,000 hospitalized cases of pneumococcal pneumonia; it is a common bacterial complication of influenza and measles. In addition, in terms of invasive disease, there are more than 50,000 cases of bacteremia and 3,000 to 6,000 cases of meningitis annually. Invasive disease bacteremia and meningitis is responsible for the highest rates of death among the elderly and patients who have underlying medical conditions. According to the Centers for Disease Control and Prevention (CDC), invasive pneumococcal disease causes more than 6,000 deaths annually. More than half of these cases involve adults for whom vaccination against pneumococcal disease is recommended.

Comments

  1. #1 D. C. Sessions
    November 28, 2009

    Don’t discount antibiotics (and good old pneumococcus) and the role they play in measles case mortality. The antivaxxers who try to claim that there was some sort of natural reduction in measles case mortality are doing their usual sleight of word: antibiotics (and oxygen) drastically reduced the mortality from measles pneumonia — there was no “glide slope” that would have made measles deaths disappear on their own.

    Some day it would be interesting to compare collections of old medical texts — $HERSELF has a copy of Meakins (among others) from 1940, plus her father’s pharmacology texts and references from the 30s.

  2. #2 Frankie Milley
    November 29, 2009

    I am the mother of an only child, Ryan, who died from of meningococcal meningitis and the founder and executive director of a national organization, Meningitis Angels.
    http://www.meningitis-angels.org.

    What is meningitis?
    Meningitis is a dangerous and sometimes fatal inflammation of the brain and/or spinal cord that can leave survivors with serious life-long physical problems such as, organ failure, blindness, deafness, loss of limbs, severe seizures, brain damage and other disabilities.
    You should also understand meningococcemia and sepsis.

    Signs and Symptoms
    The early signs of meningitis and blood poisoning which could improve detection of the disease and save lives are unrelenting fever, leg pain, cold hands and feet and abnormal skin color can develop within (12 hours) after infection and long before the more classic signs of the illness such as a rash, headache, stiff neck, sensitivity to light and impaired consciousness, debilitation or death.

    What parents and students should know:
    According to ACIP/CDC children ages (11) years through college freshmen should be vaccinated against meningococcal meningitis.

    Infants and toddlers should be vaccinated against pneumococcal and HIB meningitis.
    Those children in daycare and those of American Indian, Eskimo and African American heritage are at a higher risk for some forms of meningitis.

    There are no vaccines to prevent viral meningitis.

    Visit the American Academy of Pediatrics, Sound Advice on Vaccines: http://www.cispimmunize.org/fam/soundadvice.html

    Help Stop Meningitis!
    Please join our cause and feature on your face book page. http://apps.facebook.com/causes/103719/35941843?m=6d54c0aa

    Frankie Milley

  3. #3 Calli Arcale
    November 30, 2009

    I’m sorry for your loss. *HUGGLES* I survived meningitis (with an unknown pathogen, but probably viral) as a small child. Two weeks in the hospital. Not to nitpick, but some cases of viral meningitis actually can be prevented with vaccination. This is because some viruses better known for other symptoms, such as a measles, can also cause meningitis. But alas, you are right that most viral meningitis is probably not vaccine-preventable at present.

  4. #4 katydid13
    November 30, 2009

    I’m old enough to I went off to college without a meningitis vaccination. I’m also young enough I never wittnessed large scale parental paranoia about communicable diseases. After all we were vacinnated against the really bad stuff children were likely to get.

    Then one of my neighbors in the dorm got bacterial meningitis my sophomore year of college. She was very, very ill, but recovered without complications.

    College health services was trying to keep the circle of people it dosed with preventative antiboitics relatively small and sensible because of concerns about un-needed antiboitic use. However, several people on the floor who did not have close contact with the young woman, had doctor parents who immediately FedExed them the antiboitics. Which then of course made other people wonder if college health was holding out on us . . .

    My mother is a medical librarian at a university and our family doctor came saw her at the reference desk not long after the news broke. She asked if since I had shared a bathroom with the young woman should I have been given preventative antibiotics. He agreed that the college had the correct policy, that I was at minimal risk, but also offered to write me a perscription if it would make her feel better. She declined when she took her very concerned mother hat off and put her rational professional hat back on.

    I thought it was interesting to see how how fear in people with resources could easily trump, what they would have all abstractly called a sensible goal of reducing antibiotic over use.

  5. #5 khan
    December 2, 2009

    When I was in college (’68 – ’72). A young man died from meningitis and his roommate only survived because the other guys in the dorm took him to the hospital.

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