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.