Part 19

Summary

The exact knowledge of the mode of transmission of epidemic influenza is still wanting, but it is known to be spread by contact. Attention should be directed toward every practical means of decreasing the number and intimacy of contacts. Publicity campaigns and other educational measures should be pushed strongly. Health Departments should adopt a policy of preparedness during inter-epidemic times, should make every effort to centralize and standardize their work, and should take steps to obtain sufficient legal backing, so that upon the appearance of the epidemic they can take the lead, speak with authority and enforce their ordinances and measures. The physician’s duty is to inform himself on the value of the various measures, and if he is at odds with the public health methods, he should settle them between epidemics, so that when he is called upon to carry out public health orders he can do it to the letter and without criticism. Laymen should learn that quiet living without violent exercise, the keeping of good hours, the avoidance of public gatherings and of unnecessary exposure is the best policy to pursue during influenza epidemics. They should strictly obey the orders of those who have specialized in the control of epidemics, and all business men must stand ready to help in every possible way and to make their business interests subservient to the public good.

BIBLIOGRAPHY

1. Rosenau, Keegan, Public Health Report, 1919; xxxiv, No. 2, Goldberger and Lake p. 33. 1a. McCoy and Richey Public Health Report, 1919; xxxiv, No. 2, p. 34. 2. Lacy Jour. Lab. and Clin. Med., 1918; iv, p. 55. 3. Wollstein Jour. Exper. Med., 1911; xiv, p. 73. 4. Flexner Jour. Amer. Med. Assoc., 1913; lxi, p. 1872. 5. Park and Williams Bacteriology, 1914 Edition; p. 437. 6. Leary Jour. Amer. Med. Assoc., 1918; lxxi, p. 2098. 7. Leary Amer. Jour. Public Health, 1918; viii, p. 755. 8. Rosenau Preliminary report furnished through Surgeon-General of the Navy W. C. Braisted. 9. Barnes Jour. Amer. Med. Assoc., 1918; lxxi, p. 1849. 10. Hinton and Kane The Commonwealth Mass. State Dept. Health, 1918; vi, Nos. 1 and 2, p. 28. 11. Hinton and Kane Hinton’s Report. 12. Parker Jour. Amer. Med. Assoc., 1919; lxxii, p. 476. 13. Pearce Jour. Amer. Med. Assoc., 1913; lxi, p. 2115. 14. Committee on New and Non-Official Jour. Amer. Med. Assoc., 1918; lxx, p. Remedies 1967. 15. McCoy Personal Communication. 16. Hutchinson Dixmont Hospital Report. 17. McCoy, Murray and Jour. Amer. Med. Assoc., 1918; lxxi, p. Teeter 1997. 18. Minaker and Irvine Jour. Amer. Med. Assoc., 1919; lxxii, p. 847. 19. Sherman Report. 20. Maberry Report from Hospital for Insane, Retreat, Pa. 21. Rosenow Jour. Amer. Med. Assoc., 1919; lxxii, p. 31. 22. Beaver, Boles and Case Jour. Amer. Med. Assoc., 1919; lxxii, p. 265. 23. Ely, Lloyd, Hitchcock and Nickson Jour. Amer. Med. Assoc., 1919; lxxii, p. 24 24. Kitano Jour. Amer. Med. Assoc., 1919; lxxii, p. 1575. 25. Wynn Pract. London, 1919; cii, p. 77. 26. Norman White Lancet., 1919; i, p. 707. 27. Whitingham and Sims Lancet., 1918; ii, p. 865. 28. Cadham Lancet., 1919; ii, p. 885. 29. Eyre and Lowe Lancet., 1918; ii, p. 485. 30. Conference British War Office 31. Whitmore, Fennel and Jour. Amer. Med. Assoc., 1918; lxx, p. 427; Peterson also p. 902. 32. Fennel Jour. Amer. Med. Assoc., 1918; lxxi, p. 2115. 33. Dochez and Gillespie Jour. Amer. Med. Assoc., 1913; lxi, p. 727. 34. Lister Publications of the South African Institute for Medical Research, No. 2, 1913. 35. Lister Publications of the South African Institute for Medical Research, No. 8, 1916. 36. Lister Publications of the South African Institute for Medical Research, No. 10, 1917. 37. Cecil and Austin Jour. Exper. Med., 1918; xxviii, p. 19. 37a. Cecil and Vaughan Jour. Exper. Med., 1919; xxix, p. 457. 38. Bloomfield Johns Hopkins Bull., 1919; xxx, p. 1. 39. Capps War Med., Vol. ii, p. 371. 39a. Capps Jour. Amer. Med. Assoc., 1918; lxx, p. 910. 40. Weaver Jour. Amer. Med. Assoc., 1918; lxx, p. 76. 41. Weaver Jour. Amer. Med. Assoc., 1918; lxxi, p. 1405. 42. Weaver Jour. Infect. Dis., 1919; xxiv, p. 218. 43. Doust and Lyon Jour. Amer. Med. Assoc., 1918; lxxi, p. 1216. 44. Haller and Colwell Jour. Amer. Med. Assoc., 1918; lxxi, p. 1213. 45. Leete Lancet., 1919; i, p. 392. 46. Dannenberg Jour. Amer. Med. Assoc., 1918; lxx, p. 99. 47. Mink Jour. Amer. Med. Assoc. 1918; lxxi, p. 2175. 48. Vaughan Jour. Amer. Med. Assoc., 1918; lxxi, p. 2100. 49. Copeland Jour. Amer. Med. Assoc., 1918; lxxi, p. 2173. 50. Lynch and Cummings Jour. Amer. Med. Assoc., 1918; lxxi, p. 2174. 51. Amer. Med. Association Public Health Report, 1919; xxxiv, p. 1413. 52. Le Moignie and Pinoy Compt. rendu. Soc. Biol., 1916; lxxix, pp. 201 and 352. 52a. Wright and Douglas Proc. Royal Soc. Med., 1904; lxxiii, p. 128, and lxxiv, p. 147. 53. Neufeld and Rimpau Zeitschr. f. Hyg., 1905; li, p. 283. 54. Rosenau Prevent. Med. and Hyg., 1918. 55. Brown, Palfrey and Jour. Amer. Med. Assoc., 1919; lxxii, p. Hart 463. 56. Gay Typhoid fever. (Published by Macmillan Co., 1918.) 57. Eyre and Low Lancet. I, April 5, 1919; p. 557.

PHYSIOLOGICAL AND PHYSIOLOGICAL CHEMICAL OBSERVATIONS IN EPIDEMIC INFLUENZA

By C. C. GUTHRIE, PH. D., M. D.

The material consisted of cases in the acute stage of epidemic influenza with and without clinical pulmonary involvement (alveolar); of convalescents, and of normal individuals without influenzal history.

It was hoped that it would be possible to follow selected cases over considerable time periods, observation to compromise coordinated clinical as well as laboratory data, but the exigencies of the situation rendered this impossible. Unfortunately, this limits the value of the studies. But since similar observations were made on cases ranging from normal to the gravest severity—in fact, preceding death but a few hours in some instances—and from the nature of the findings, certain conclusions are clearly warranted.

It is regrettable that the data on certain points is not more extensive, and particularly that other methods of observation were not employed. As an example of the latter, measurements and analyses of expired air may be given, as this was planned from the beginning and unsuccessful efforts made to provide the required apparatus. In view, however, of the circumstances of the investigation, it is felt that the studies made are, on the whole, reasonably comprehensive and complete. And it is only fair here to acknowledge that this was rendered possible by the cordial and practical support of the Medical School, the military authorities, the director of the laboratories, clinical colleagues, particularly Dr. W. W. G. Maclachlan, and last, but not of less importance, of the members of the department who made the studies.

In presenting the results, it is deemed most expedient and practical to omit extensive tabulations and to summarize the data under each subject.

From the report it will be obvious that certain studies were in preliminary stages at the termination of the investigation. This was due in certain instances to the lateness of their undertaking, or time consumed in providing essential equipment and methods; or to disappearance of suitable cases due to waning of the epidemic.

RESULTS

Circulation

For the most part, cases showing marked clinical symptoms were studied. The pulse in severe cases frequently was weak and rapid but regular. In some cases it was less rapid than the clinical state would seem to indicate.

Arterial Blood Pressure was low; systolic pressure in severe cases ranging downward from 95, and diastolic down to 40 or under. In patients in early stages of convalescence the pressure showed a marked advance toward normal levels. Arterial blood pressure seemed a reliable general index of the condition of the patient.

Venous Blood Pressure.—The observations included patients who a few hours later expired. The Von Recklinghausen method was used. No marked abnormality was observed, so other methods of observation were deemed superfluous.

Respiration

In severe cases, frequently it was rapid and of shallow character; but, like the pulse, often it was less rapid than the clinical state would seem to indicate.

Cyanosis of dark hue and marked degree was prevalent in the earlier severe cases, and in some cases appeared entirely out of proportion to the state of circulation and respiration and to the post-mortem findings as reported by Dr. Klotz.

Blood

Hemorrhage being not uncommon, the blood was tested for coagulability, but in this respect no marked departure from the normal range was noted.

Coagulation.—Coagulation time was observed by stirring blood in a test tube with a wire and noting the time of the appearance of fibrin and by means of a Biffi-Brooks coagulimeter. The extreme ranges observed were from 2½ to 5½ minutes. The average by defibrination was 3 minutes and 36 seconds, and by the Biffi-Brooks method 4 minutes and 38 seconds.

Red Corpuscles.—Osmotic resistance. A number of bloods were examined by observing their resistance to osmotic laking by exposure to a series of hypotonic sodium chloride solutions. Though some differences were observed, from the evidence obtained, it is not permissible to conclude that such variations were constant or of a significant magnitude.

Color on exposure to air. It was early observed that venous blood from cyanotic patients was very slow to take on arterial hue on exposure to air.

Plasma Bicarbonate.—The plasma bicarbonate was determined in seven cases by Miss Waddell by the method of Van Slyke and Cullen. In all except one of these the results were within the normal range as given by Van Slyke. Three were in the lower normal range, being 54.1, 55.1 and 60.5 respectively, expressed in terms of cubic centimeters of CO{2} reduced to 0°, 760 mm. Hg. pressure, bound as bicarbonate by 100 c.cm. of plasma. Three were in the median range, being 64, 65.5 and 71 c.cm. In one case the bicarbonate CO{2} was reduced to 46.6 c.cm.

There seemed to be no constant relation between the apparent severity of the clinical condition of the patient and the bicarbonate reading. In the one case in which this was found to be reduced below Van Slyke’s lower normal limit the blood was taken only a few hours before death.

Hemoglobin Per Cent.—As determined by the Sahli hemoglobinometer (by Miss Lee) and as estimated by the total oxygen capacity (Van Slyke method) (by Dr. Rohde and Mrs. Macklin), the hemoglobin content ranged within normal levels.

Relative Volume of Corpuscles.—A limited number of hematokrit tests on severe cases gave results in normal levels.