A century of South African battles against the pneumococcus –‘the captain of death’

Abstract

A hundred years ago, Sir William Osler described the pneumococcus as the ‘Captain of the men of death’, referring to John Bunyuan’s phrase in his book ‘The life and death of Mr Badman’, written more than 200 years earlier: “Yet the captain of all these men of death that came against him to take him away was the consumption, for it was that that brought him down to the grave”. For Osler the captain of the men of death was not ‘consumption’ (tuberculosis) but pneumonia or the pneumococcus. During his time, acute pneumonia was responsible for more deaths than tuberculosis and the pneumococcus killed adolescents and young adults in the prime of their lives. Death followed a severe illness with high fever from 105°F to 107°F, fighting for air with rapid and shallow, often painful breathing. The condition escalated to a crisis, characterised by a sharp fall in temperature, and in many, death. Concerning those that recover Osler states, “Usually there is an abundant sweat and the patient sinks into a comfortable sleep” and “With the fall in the fever the respirations become reduced almost to normal, the pulse slows, and the patient passes from perhaps a state of extreme hazard and distress to one of safety and comfort”. Osler also called the pneumococcus the ‘friend of the aged’ as it kills them gently without severe symptoms (“Taken off by it in an acute, short, not often painful illness, the old escape those ‘cold gradations of decay’ that make the last stage of all so distressing”) and “one may say that to die of pneumonia is almost the natural end of old people”. The advent of antibiotics in the 1940s dealt a severe blow to the captain’s reign of terror and thanks to them the harshness of the escalating severity and crisis by death is now muted or rarely seen among young adults, at least in industrialised countries. It remains, however, a captain of the men of death among HIV-infected adults with limited access antiretroviral treatment and also among small children in the poorest countries without access to antibiotics. Small wonder the consternation then, when multiresistant strains emerged in South Africa in the 1970s.