Newsmaker: pneumonia

A little over a century ago Canadian doctor William Osler, one of the founders of the Johns Hopkins Hospital in Baltimore, wrote that “pneumonia may well be called the friend of the aged”.

What he meant, as he went on to explain in his 1909 book The Principles and Practice of Medicine, was that: "Taken off by it in an acute, short, not often painful illness, the old man escapes those 'cold gradations of decay', so distressing to himself and to his friends." Usually, death by pneumonia was over and done with within a week.

Osler himself wasn’t so lucky. A decade later, on December 29, 1919, he lost his life at the age of 70 to the disease that had, as he noted, usurped the office of tuberculosis as “the captain of the men of death”. But his end, in bed in Oxford, England, was an extended and miserable one, leaving him “very ill and emaciated, in a state of extreme toxaemia [septic shock], and speaking little because speech brought on a bout of paroxysmal coughing”, according to one account.

But if pneumonia is the friend of those whose life is drawing to an otherwise long and miserable close, it most certainly is not the ally of those seeking the highest office in American politics, as United States Democratic presidential nominee Hillary Clinton found this week, possibly to her eventual cost at the polls.

By the standards of today’s medicine, Clinton, 68, does not qualify as “the aged”. But her public stumble on Sunday under the influence of a bout of “walking pneumonia” serves as a reminder that a disease first recorded (and named) by the Greeks remains a potent threat to us all, humble or mighty.

Though described by Hippocrates in about 400 BC in his treatise On Regimen in Acute Diseases, it was Maimonides, a medieval physician from what is now Spain, who nailed it with his description in the 12th century, which pretty much holds today: "The basic symptoms that occur in pneumonia and that are never lacking are … acute fever, sticking pleuritic pain in the side, short, rapid breaths, serrated pulse and cough."

But it wasn’t until 1875 that a German pathologist, Edwin Klebs, first identified the pneumonia bacteria under a microscope. Once commonly known as the winter fever, pneumonia is more common in the colder months, when people tend to be in closer proximity to one another and are more likely to spread bacteria and viruses (top tip for infected politicians hoping to become president: stop embracing children, as Clinton did in front of the assembled media on Sunday). It’s caused by an infection that inflames the small air sacs, the alveoli, in one or both lungs (double pneumonia). Usually, a bacteria called Streptococcus pneumoniae is to blame, but various other types of bacteria, viruses and even fungi can trigger the reaction, and in some cases the cause is never isolated.

Whatever it is that’s irritating them, the alveoli start to fill with pus and other fluid, hampering the ability of the lungs to pass oxygen around the body via the blood. This is made worse as the body starts to fight the infection, as the white blood cells sent to the scene to beat off the invader further clog up the sacs.

As the lungs fill increasingly with liquid, if pneumonia is untreated it can leave a sufferer feeling as though they are literally drowning in their own fluids.

Today, pneumonia needn’t be a serious problem, provided it’s treated promptly and correctly. The “walking pneumonia” ascribed to Clinton, in fact, describes only a mild case, which can be checked, usually within a week, by antibiotics combined with rest and plenty of fluids.

Initially, pneumonia can be mistaken for a common cold, but severe symptoms can come on quickly and worsen rapidly – coughing up phlegm, sneezing, high temperature, sweats and chills, and breathing problems. Rapid breathing, sometimes accompanied by dizziness and confusion, is a sign of a bad case. If taking a deep breath causes a sharp pain in the side of the chest, then pleurisy has set in – infection and inflammation of the outer covering of the lung, which can lead to respiratory failure. In both cases, an urgent trip to the hospital is vital.

In the days before the modern era of antibiotics, a bout of pneumonia was a death sentence – by 1918, it had replaced tuberculosis as the world’s number-one killer. Over the centuries since the disease was first described by Hippocrates, various remedies have been tried. Right up until the late 19th century, blood-letting, a last-resort “cure-all” invented by the ancient Egyptians and relied upon for centuries by doctors with nothing better to offer, was all the rage for pneumonia. In the 18th century an Austrian princess with the disease was bled not once, but three times on consecutive days. On each occasion she lost three or four pints of blood and, as a contemporary account noted with apparent surprise, “notwithstanding the active bleeding, the patient died”. In 1799, George Washington may have gone the same way.

By Osler’s time, treatment, still ultimately useless, was limited to sedation and sticking long needles into the lungs to draw off whatever could be found. In his case, a first stab at this produced only “a little serous fluid, drawn off without any relief of symptoms”. Longer needles were produced, and this time “between 4ml and 5ml of stinking pus was withdrawn”, though to no avail. Days later, Osler died coughing up blood from a ruptured vessel in his lung.

Everything changed after 1932, when Gerhard Domagk, a German bacteriologist, discovered that sulphanilamide, a molecule found in a red commercial dye called Prontosil, killed the bacteria responsible for most cases of pneumonia. He got as far as showing that it worked on mice infected with Streptococcus pneumoniae, when fate speeded up the slow, systematic progress to human trials.

In 1935, Domagk’s six-year-old daughter cut her hand, and the wound turned septic. As the infection spread, and doctors prepared to try to save her life by cutting off her arm, a desperate father gave his daughter a massive dose of Prontosil. It worked. Prontosil – a decade before penicillin became widely available – was the world’s first antibiotic. At the time, it was a miracle drug, and the discovery earned Domagk the 1939 Nobel Prize.

"It was clear that the disease, which in the days of Osler could be treated by no more than palliatives, stimulants, sedatives and careful nursing, could now be easily and cheaply controlled," concluded an article in the British Medical Journal in 1951.

There was a slight drawback. A side effect of sulphapyridine was “intense vomiting … which led some who owed their lives to the drug to declare that they would prefer to die rather than endure the treatment again”.

Within a short while, however, “penicillin came to be sufficiently plentiful for everyday use”, and that life or death decision was no longer necessary. But although death rates around the developed world dropped when antibiotics became common, the disease has remained stubbornly ever-present.

The death rate from pneumonia in the United States, for example, “has had little or no improvement since antibiotics became widespread more than half a century ago”, says the American Thoracic Society. Today, about a million adults are hospitalised with pneumonia every year in the US, and 50,000 of them will die.

The problem, says the society, which represents lung specialists, is that pneumonia lacks “effective advocacy. It is not the subject of fundraising walks or runs. It does not have a ribbon or other symbol around which people rally. It does not get the attention it needs from biomedical scientists or from research funders.”

And, while pneumonia targets those whose immune systems are fragile – especially the very young and the very old – half the deaths in the US are among people between the ages of 18 and 64. Smokers and heavy drinkers are particularly vulnerable. Like flu, pneumonia is contagious; as the old saying has it, “coughs and sneezes spread diseases”.

But pneumonia remains a serious, if neglected, problem in the developed world, despite the widespread availability of vaccines to prevent it and antibiotics to treat it. The disease is the leading global killer of children under 5 years old, accounting for 15 per cent of all deaths. In 2015 the World Health Organisation estimated it killed more than 920,000 children – overwhelmingly in the developing world.

Fifteen countries account for the bulk of the 113 million global cases of childhood pneumonia each year: top of the list, with 44 million cases, is India, followed by China, with 18 million.

Whether or not Clinton’s pneumonia proves fatal to her presidential ambitions, it will doubtless saves lives among those of a similar age who will be prompted by the media coverage to seek a vaccine. That effect is unlikely to spread, however, to those in the developing world, where the curse of pneumonia – a preventable and treatable disease – remains the leading killer of children under the age of 5. That will be the central message of this year’s World Pneumonia Day on November 12: “We have the tools necessary to prevent and treat this disease. It’s time that we put these tools to work and get them where they are needed most … every breath counts.”

weekend@thenational.ae