Part 10

At the beginning of the epidemic we prescribed whisky in almost every case. Our idea was that it would have a sedative action. At the present time we are very doubtful of its value. Toward the end of the epidemic we used it very moderately. The results obtained possibly depended for the most part upon the type of patient. Some of the soldiers asked to have it discontinued, not from any moral point of view, while others wished more frequent doses. The elderly patients seemed to appreciate this remedial agent to a fuller extent.

Pneumonia

The pneumonia following the original infection was, from the standpoint of physical diagnosis, often difficult of diagnosis in its early stages. The infection commencing as an influenza would at times pass imperceptibly into pneumonia, and obviously the points brought out in the previous paragraphs on treatment were applied until the diagnosis of pneumonia had been established. Some new factors were peculiar to the pneumonia and demanded further changes in the handling of the cases.

We would again emphasize the value of careful nursing to conserve the patients’ strength. They should be kept warm, well covered, with plenty of fresh air. Water should be given regularly and abundantly. The diet should be light, one depending a good deal upon the severity of the case. We believe it is safer to limit the diet to fluids while the infection is still pronounced, but as soon as the crisis has passed one may increase the diet freely and fairly rapidly.

Regular elimination from the bowel should be helped by the use of castor oil every other day, the dosage made to comply with the patient. We noticed much less abdominal distention in this form of pneumonia than one is accustomed to see in the ordinary lobar pneumonia. If distention were present, plain soap enemas with turpentine gave very satisfactory results. Turpentine stupes also are of considerable value. Rest at night is needed. When a hypnotic was necessary we gave morphine (gr. ⅙), and repeated if the desired results were not obtained.

The day is coming when we are going to isolate our pneumonia cases. This was almost an impossibility during the stress of the past epidemic, but we know that temporary and fairly satisfactory methods can be applied. Many hospitals provided for a type of isolation. In a pneumonia ward sheets stretched between the beds keep the fine spray which a heavy cough always produces from spreading over the next two or three beds. This method is simple and can be easily carried out. We feel almost certain of having seen convalescent influenza cases develop pneumonia from the adjacent pneumonia patients. As much as is physically possible, the uncomplicated influenza and the pneumonia cases should be separated. Further, it is to be kept in mind that reinfection by another group of pneumococcus is quite possible, even in a ward containing only pneumonia patients.

We did not observe any special effect of quinine, salol, salicylates after the pneumonia had developed and, therefore, these drugs were discontinued. Digitalis in the form of the tincture was at first made a routine measure, but toward the middle of the epidemic we stopped this routine usage and gave it only as it appeared to be indicated. Our impression was that the heart was not involved as it is in ordinary pneumonia. A slow, full pulse, as was so often the rule, did not seem to require digitalis. For more rapid action of the drug one of the hypodermic digitalis preparations or strophanthin was given.

Caffein sodium benzoate or salicylate seemed to be of considerable value given hypodermically every two or three hours, the last dose at 4 P. M. Its action as a respiratory stimulant and also as a diuretic was what we desired to obtain. The drug was used fairly early in the pneumonia, and although it was never prescribed routinely we gave it frequently.

Atropine was indicated whenever signs of œdema were evident. Its action was not always successful, but in certain severe cases we believe that large repeated doses of atropine saved a few lives. One-fiftieth (1/50 gr.) grain hypodermically, repeated every hour for several doses, was usually well borne. We noticed twice in each of two cases after using small doses (1/100 every four hours) a peculiar rapid cyanosis not associated with dyspnœa develop. This reaction remained, however, for only a short time, about 15 to 20 minutes, but it was rather alarming while it lasted.

The drug therapy is not very satisfactory in lobar pneumonia, and it is less so in the form of pneumonia which follows influenza. There is practically nothing essentially new in the drug and general treatment of this serious complication over what was shown in 1890, or even in the earlier epidemics, save that our nursing and hygienic measures are undoubtedly better.

The addition of an immune serum (anti-pneumococcus serum No. 1) to the treatment of pneumonia is a milestone in the history of the handling of this disease, but we must keep in mind that the pneumonia of the past epidemic was not the usual pneumococcic lobar pneumonia. That the pneumococcus was present in a great many cases is shown in another article of this series, but we also know that the B. influenzæ was present in many, and that it played an active part in the disease is evidenced by the constant low blood count or actual leucopenia. A leucopenia in true lobar pneumonia is most unusual in the United States. The rarity of Type I pneumococcus was noteworthy. We were practically unable to get any anti-pneumococcic serum which was known to be of value at the time of the epidemic, so naturally could not apply this method of treatment as was desired. About half a dozen 50 cc. bottles were in possession of the army medical officers here, but they unfortunately could get no further supply after this was used. We would have liked very much to have combined the anti-pneumococcic serum in Type I cases with the citrated convalescent blood, as was used by us during the epidemic. The anti-pneumococcic chicken serum of Kyes should also be considered. This serum has had but a very localized trial, but from competent observers who have given it to a considerable extent in some of the army camps we are led to believe that it has a very definite value. Major Lawrence Litchfield informed the writer that he had observed excellent results with Kyes chicken serum during the past epidemic in the treatment of pneumonia. This serum was not available for our use. It is to be hoped that further experience with Kyes serum will be favorable, because from the practical standpoint in the treatment of pneumonia it has many commendable features. Again, we desire to point out that the use of anti-pneumococcus sera in influenzal pneumonia may not be a fair test of their true value.

Very early in the epidemic we realized that the pneumonia was of unusual severity and most difficult to treat satisfactorily. We were at once impressed by our helplessness, particularly in those patients showing cyanosis. Nothing we did seemed to vary the course of the pneumonia after this sign was evident.

Our work in the epidemic began about October 10 on receiving a large batch of soldiers, about 100, from the Student Army Training Corps of the University of Pittsburgh. At the end of the first week several points were impressed on our mind. Firstly, in the severe cases of pneumonia; and in the early part of the epidemic most of the pneumonia was severe, the mortality was excessive, much higher than we have been accustomed to experience in Pittsburgh, where, as a rule, our hospital ward pneumonia is a very severe infection. Secondly, the wide variation in the severity of the epidemic as presented in the student soldiers coming from identical surroundings and conditions, the mildness on the one hand and the malignant character of the influenza on the other, was a very striking feature. This led to our adopting a form of treatment which was quite successful.

We worked purely on the hypothesis that those individuals recovering from a mild or moderate influenza infection developed a higher grade of immunity than those in whom the disease was more severe or fatal, and this immunity could be transferred to another. This, of course, was merely inference. If the mild cases did present a higher immunity, one would naturally think that immune bodies would be present in the blood, and that in transfusion from cases which had recovered one might have a measure of therapeutic value for this epidemic. Recently Spooner, Scott and Heath and others have demonstrated specific agglutins in the serum of patients convalescing from the epidemic. On October 17 we gave whole citrated blood from a convalescent case of uncomplicated influenza to an influenzal pneumonia patient. The result in this case was strikingly good, and for the following five or six weeks this method was frequently used. We decided to give the whole blood instead of the serum, as we were able to treat the cases more readily and rapidly in this way. Our method of transfusion was, fortunately, very simple.

We had treated but a few cases when the report of McGuire and Redden appeared. These observers working in the Naval Hospital at Chelsea, Mass., presented very excellent results in the use of immune serum from convalescent influenza cases in the treatment of pneumonia. They reported 30 recoveries out of 37 cases, with 1 death, and 6 cases still under treatment at the time of their report. This form of treatment began at Chelsea on September 28, 1919. In Texas, on October 15, Brown and Sweet gave two cases of influenzal pneumonia citrated blood from convalescent influenza patients. Their two cases recovered. Our published results, although not showing such excellent figures as from the Chelsea observers, agree very well with their work.

Since that time a number of confirmatory reports have been brought forward. Ross and Hund have shown that this method has been of value in their hands, and recently a further statement from McGuire and Redden tends to confirm their first views as to the value of immune serum from convalescent patients. Their last report giving a mortality of 6 in 151 cases of pneumonia cannot be other than positive proof of the value of this method of treatment.

As the technical side of the work has been given in several articles, we hardly think it necessary to again review it in detail. A few phases should, however, be recalled. It would seem that either serum or the whole citrated blood may be used. Solis-Cohen and his group of workers believe that whole blood has stronger bactericidal properties than defibrinated blood or the plasma. But yet one cannot complain, even on a theoretical basis, against the results obtained with serum by McGuire and Redden. The use of whole blood increases the detail of the procedure, in that the agglutination reactions must be estimated. Unfavorable results in this regard also naturally cut down the supply of available donors. In a military hospital a dearth of donors does not arise, but in civilian practice the problem is very different. In our work we never gave more than 100 cc. of whole blood; usually the amount varied between 50 cc. and 75 cc. On account of the small amount we felt that isoagglutination would not be a serious factor, and in more than 200 injections we failed to see any evidence of ill results from this source. Giving up to 500 cc., as was done by Ross and Hund, is probably a different affair, and accurate agglutination tests are essential. We feel that if the case is treated sufficiently early in the disease as much good can be shown to occur after 50 cc. as after 100 cc. of blood. We do believe, however, that the pooling of sera, where one is able to carry out this method, as it means a liberal supply of donors, is really the method of choice. Syphilis must be ruled out, both clinically and serologically.

As we emphasized previously, the problem presented in the army hospital and in civilian practice is a little different. We have had some experience with both sides. Fortunately, the greater part of our work was with the Student Army Training Corps, where army conditions were more or less carried out. There was never any difficulty in getting donors. In fact, the idea of giving blood appealed to these young fellows. In civilian life it is, in our experience, a more difficult problem. The usual personnel of the public ward has always its fair percentage of positive Wassermann reactors, and the type of individual is quite different from the young soldier. For a relative or friend we could easily get a donor, but this group would cover only a small percentage of the cases one wished to treat. The technique of giving blood can be reduced to a very simple procedure, and by no means should be regarded as a difficult surgical undertaking. Combining the receiving apparatus of Ross and Hund (J. A. M. A., 72, 1919, p. 642) with the syringe method for giving the blood which we suggested in our previous article makes an ideal arrangement.

The results depend upon the time of treatment. The earlier the pneumonia is recognized the better are the chances of recovery. It is our belief that the majority of influenza cases which kept a fairly high temperature for more than four days had a lung lesion, even if we could not make out definite consolidation. As the convalescent influenza serum may have value only for the influenza infection, it would, therefore, appear but logical that a late pneumonia which almost always has other organisms present would not react as favorably. We have seen very few of the deeply cyanotic type recover even with serum. The essential rule is to treat them before this stage develops.

We have observed little or no change in the leucocyte count, even after successful treatment, and taking our group as a whole we are rather surprised at this result. Other observers have noticed a marked increase in the leucocytes as the case reacted favorably to the injections. We agree with McGuire and Redden that the patients with counts below 10,000, as a rule, show the best results. This possibly indicates that the influenza infection is predominating, and that the usual secondary invaders (pneumococcus and streptococcus) are at this time playing but a little part. Hence the value of early treatment is apparent.

From the published results of different workers and our own experience, we feel that influenza immune serum or whole citrated blood given early in the pneumonia is of undoubted value—in fact, almost specific. If the epidemic reappears next year, unless some other better method is forthcoming, we would advise its more general use, and would suggest the collection of pooled serum as early as possible in the epidemic.

At the end of this article there is appended a series of our ward record charts of patients who developed pneumonia following the influenza. These charts are shown to indicate the results of giving immune convalescent citrated blood in pneumonia. The ones presented are from some of the group which recovered. We have, of course, the charts from the fatal cases, but as they do not bring out any special point, save that there was little or no change after treatment, we are omitting them. It is not our idea, however, to give the impression that we have had nothing but success with this method of treatment. It might be well to emphasize some of the salient points which are brought out.

(1) The regularity of the drop in temperature after the injection is almost generally demonstrated.

(2) The occasional chill following the injection seemed to have no untoward results.

(3) The leucocytes show, as a rule, little or no variation after transfusion. Our work agrees with McGuire and Redden’s statement that the cases with a leucocyte count under 10,000 give the best results with immune serum.

(4) The time of injection in many of the cases was by no means ideal, in that the disease was advanced; and again in many the injection should have been repeated sooner. This, however, is no fault of ours.

(5) One injection of 50 cc. of citrated blood from a good donor, if given early enough, may be all that is necessary. Several charts bear out this statement.

(6) The day of disease is dated from the onset of the influenza. The demonstrable signs of pneumonia correspond roughly to the initial rise in temperature following the influenza. The day of disease of the pneumonia is not indicated on the chart, as this information we have obtained from the daily notes.