By W. W. G. MACLACHLAN, M. D.
One may frankly say there is no specific treatment for influenza.
Possibly we are in error in introducing the discussion, particularly on
treatment with such a definite and unsatisfactory conclusion. The same
statement has been made after all the previous pandemics, and one
wonders whether a like remark is going to apply to the next similar
scourge. The past two or three months should bring to the medical
profession a certain humility which should stimulate a keener sense of
research, especially as we now have at our disposal highly organized
laboratories where unsolved problems can be viewed from almost any
angle. Yet we are really, save here and there, putting our forces
together in the study of the disease. It is obvious that a fleeting
epidemic makes a most difficult subject for study, especially during a
time when there is a paucity of physicians. May we not hope, however,
that some researches on the disease may be forthcoming, so that we may
safely feel that at least preventive or protective measures will be
possible?
There is no one who is able to say that this or that drug has not been
thoroughly tried. The alkalies, salicylates, antipyretics, quinine and
the sedatives have all been freely used in the last as well as the
present epidemic. Each group of drugs has its following, although it
appears to be a general rule in this epidemic to use the antipyretics
(coal tar products) as little as possible. From the distant past we have
numerous records of treatment. Willis (1658) emphasized the value of
sweating and the use of diaphoretics, but at the same time he states
that in mild cases the cure is left to nature; Sydenham (1675) claimed
considerable value in fresh air. He also paid more attention to
restricting the diet, and was not favorable to the use of anodynes. One
certainly obtains the impression from the records of past epidemics that
many of the general principles in treatment were similar to what are now
in vogue. Medicinal remedies, of course, varied greatly, but to
enumerate them would be merely giving a résumé of the progress of
therapeutics. Sufficient is it to say that influenza has certainly,
since the earliest days, given therapeutists an ample opportunity to
test their wares.
The outstanding respiratory complication, pneumonia, has added a very
undesirable phase to the disease. In fact, the greater part of the
mortality was due to this serious sequela. Some interesting points have
been brought out in serum and blood therapy for this type of pneumonia.
The use of whole blood or serum from convalescent patients in cases of
pneumonia opens up a new and not unlikely fruitful means of treatment.
The method of treatment possibly may be applicable as an emergency
measure in other diseases, as has been shown in the case of scarlet
fever and poliomyelitis. We also have the anti-pneumococcic sera
available for therapeutic use. The drugs and the general treatment of
the pneumonia are virtually the same for the last two epidemics.
The protean manifestations of the 1890 epidemic, with its unusual
nervous sequelæ, have not been seen to any extent, as far as we yet
know. In fact, the present epidemic appears to be relatively free from
complications other than those occurring in the lung during the acute
course of the disease. Hence, in all likelihood, there will be less of
the nervous after effects to be treated. It is, however, too early to
hope that the nervous system is going to escape.
In another part of this volume the vaccine therapy is discussed in
detail, so that we shall not repeat what has been brought out in that
article. We would, however, emphasize the value of honest and accurate
clinical reports of the use of vaccines, in order to establish their
present status in epidemic influenza. Overestimation and commercialism
are very likely to ruin a method of treatment, even when it may be of
value in a certain phase of the disease. If we do not carefully weigh
the pros and cons of the vaccine treatment in this epidemic from a
purely scientific and coldly neutral attitude, we are simply doing the
public and ourselves an injustice.
The treatment of influenza as the disease presented itself to us in this
community will be considered under three divisions—acute influenza,
pneumonia, and other complications.
_Acute Influenza_
There is one important thing to be done in the treatment of influenza,
whether the infection be mild or severe. Have the patient go to bed as
soon as possible. In most of the acute attacks the individual went to
bed of his own accord; but there were, unfortunately, too many instances
where the patient refused to surrender, trying, as we say, to fight the
attack. Some appeared to be able to accomplish this feat. But how many
of our cases of fatal pneumonia can be clearly linked up with this group
of the mild or subacute preliminary course? No matter how light the
attack may appear to be, the patient should be told of the necessity of
remaining in bed until the pulse, respiration and temperature have
returned to the normal and remained normal for at least five days. At
the onset a hot bath, with care to avoid chilling, followed by a drink
of hot lemonade and a Dover’s powder, gave considerable relief to the
patient.
The value of good nursing cannot be overestimated. The nurse must see
that the patient is always well covered and kept warm, not even
permitting him to rise in bed to reach for a drink; also the regulation
of the temperature of the room should be carefully watched. The main
point is to have plenty of fresh air. We have noticed that the patient
appeared more comfortable if the air was slightly warmed. Water should
be given at regular intervals. Under no consideration should an acute
influenza case be allowed to get up to go to the toilet.
At the onset, and while the febrile attack is still present, there is
little desire for food—but one does not need to worry about the question
of nourishment in such an acute illness. Milk, cream, cocoa, gruels and
fruit juices may be given at first, and as the fever subsides the diet
increased. We have found that the appetite returned to normal very
readily. In view of the urinary findings indicating a slight transient
nephritis, meat broths are to be avoided until the convalescent stage is
reached. We have been very guarded in recommending cold sponging in
acute influenza. As a rule, it was not necessary. The icebag to the head
is often of great value in the intense headache, which is so frequent.
It is our opinion that in the treatment of uncomplicated influenza what
has just been mentioned constitutes the important part. Most physicians
would agree with this. However, when we advance to drug therapy, we come
into the personal realm of likes and dislikes of drugs and methods of
usage.
We do not intend in any way to give our views in a dogmatic manner, nor
to touch upon all of the remedies that have been advanced. At the onset
of the disease a moderate calomel purge, followed by a saline, was given
in all cases. We were practically free from the so-called intestinal
type of influenza which was seen in some other communities, consequently
we did not hesitate to use calomel. Castor oil or magnesium sulphate was
given afterward, as was found necessary. Abdominal distention was rarely
seen, and when it occurred a plain soapsuds enema with turpentine was
administered.
Quinine sulphate (gr. iii-v, three times a day) combined with
phenyl-salicylate (gr. v) was a routine measure. We often noticed
deafness after a very few doses of quinine. It was then discontinued.
Acetyl-salicylic acid (gr. v, three to six times a day) seemed to have a
palliative effect on the severe headaches, although during the height of
the disease the general muscular aching did not appear to be relieved by
its use. It was not used routinely. These drugs possibly made the
patients more comfortable, but we were very skeptical as to their
influence on the general infection. The raising of the leucocyte count
by quinine in influenza appears very unlikely. The use of alkaline salts
has been a general procedure, particularly as we are now on the alkaline
wave of therapeutics. Sodium bicarbonate was added to the drinking water
of all patients (two drams to the quart). We gave this salt for its
diuretic effect. In a few cases more active diuresis by the alkalines
was readily and easily produced by the use of “imperial drink” three or
four times a day. We felt that good kidney elimination was of
considerable importance.
The use of tartrates and citrates, as in “imperial drink” in a condition
where we know some kidney impairment is present, is possibly flying in
the face of danger—especially in view of the fact that these salts are
so available in the production of experimental nephritis. But we have
only to see their application in the human in mercury bichloride
poisoning, where an intense nephrosis usually develops, to fully realize
that these salts may be given without danger to the kidney. We do not
suggest that the kidney lesions of influenza and mercury bichloride
poisoning are the same. We are merely bringing out this point of analogy
in support of their use in certain desirable cases.
The respiratory symptoms gave us more concern than any other phase of
the uncomplicated case. The irritating, distressing, non-productive
cough suggested both a sedative and expectorant. Ammonium chloride (gr.
iii-v, t. i. d.) was the usual expectorant. It seemed to increase in
value with the more chronic type of case. It is our impression with
those acute hacking coughs that the sedatives produced more gratifying
results. Elixir terpin hydrate with heroin, codeine and occasionally
morphine were preferred. When good results were noted sedatives were
given liberally. Steam inhalations combined with tr. benzoin co.,
followed by spraying the throat with medicated liquid petroleum, gave
some relief. The tendency to œdema, however, as we saw it in the cases
complicated by pneumonia made us hesitate to use inhalations. Possibly
the fear was groundless. Morphine (grs. ⅙) was given for sleeplessness,
and it was repeated if necessary.
Cardiac stimulants were rarely needed. The tincture of digitalis was the
choice, but in the uncomplicated cases was very seldom used.
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.
_Complications_
The epidemic was well spent before we observed many complications, save
those referable to the lung. Later various forms of sequelæ have been
appearing. One must guard, however, against the danger of attributing
all of our ills to the past epidemic. We are not going to give in detail
the treatment of these various conditions, nor even mention all of the
many complications. The main points, however, we desire to emphasize.
We have previously considered pneumonia, which is the principal
complication with simple influenza, and the two are closely allied. As
an end result of the pneumonia, non-resolution and fibrosis of the lung
are of first importance. We cannot say very much on the treatment of
this condition. The duration varied from a few to several weeks, and
recovery was infrequent. Our treatment aimed at supplying as much
nourishment as was possible to give, with, in addition, good nursing.
The treatment otherwise was purely of a general hygienic type. Tepid
sponging appeared to give considerable relief from the profuse sweating
these patients so often had. Drugs were of value only for some local
effect. We wonder if carefully handled vaccine therapy at the onset of
such a complication might not prove of some value. The autogenous would
be the one of choice.
Empyema was not found to be as prevalent as one would imagine. With so
much non-resolution of lung following the pneumonia we were surprised to
see so little empyema. All delayed resolutions we explored with the
needle, so we feel that the condition, if present, would have been
recognized. The treatment of empyema need not be given any special
emphasis. It is, as of old, a surgical affair. One or two new points in
the technique have been brought out in the way of drainage, but possibly
they have not been sufficiently tried to lay any stress upon them at
present. Dakin’s solution in certain chronic cases appeared of value.
Our empyema cases did well.
Pleurisy with effusion was observed a number of times, although it has
been our experience to find a very few large effusions. Pleural puncture
often gave negative results, even when the signs did appear to indicate
the condition. We aspirated the fluid when present. The end results were
always good. In only one case did we have to repeat the aspiration for
reaccumulation of fluid.
Chronic bronchitis, accompanied at times with considerable dyspnœa, has
been seen on several occasions. There is very likely associated with
this condition some fibrosis of lung, and probably some organization of
small bronchioles themselves. Expectoration has been variable, profuse
or scanty, mucoid or purulent. We consider rest in bed, with as full a
diet as possible to build up the general condition of the patient, the
best form of treatment. These cases had little or no temperature, and
consequently at first absolute rest was not considered necessary, but we
now regard it as the essential part of the treatment. Atropine and
heroin are of value at certain times. We confess to have seen very
little benefit from the expectorants. We are rather surprised that this
sequela is not of more frequent occurrence.
Phlebitis, in our series usually of the formal vein, occurred about as
often as it does in typhoid fever. The end result, however, is much
better than in typhoid. We have seen only one case where “the milk leg”
has resulted. Rest and elevation of the limb were all that we required.
In the acute stage, if pain was present, a light, carefully applied
icebag was added. It is important to rest the limb for at least two or
three weeks, and to caution the patient against remaining on the feet
too long for some weeks after recovery.
We saw a great deal of acute sinus infection, often occurring even while
the attack of influenza was present, but, as a rule, this complication
followed the attack. At times several weeks intervened. The ethmoidal
sinuses are most susceptible, but a considerable number of acute frontal
sinus infections were noted, the latter often immediately following or
occurring during the acute period of the influenza attack. The majority
of these infections appeared transient, and disappeared with a little
local treatment. In fact, in frontal sinusitis cold applications seemed
to be all that was necessary. With some of the more chronic infections
nose and throat surgery has been followed by relief of symptoms. Acute
suppurative otitis media, considering the number of influenza patients,
was not common. Ear drum puncture was done if necessary. We saw one case
of acute mastoiditis develop. The mastoid process was opened and
drained.
Acute suppurative meningitis, following or associated with pneumonia,
appeared on three occasions. The pneumococcus was cultured from the
spinal fluid in all cases. Anti-pneumococcus sera intraspinally (Type I
or the Kyes serum) should be given. The Type I serum is of value in a
similar group infection. We have had no experience with this method, but
some recoveries from pneumococcus meningitis have been reported after
the early use of serum given into the spinal canal.
Following the 1890 epidemic cases complaining of blindness or partial
loss of vision, with optic œdema or neuritis and a glycosuria, were
occasionally observed. We have seen one of this type, and several
transient glycosurias without eye signs or symptoms. The glycosuria may
be of nervous origin. Our method of treatment was one of elimination and
rest. The gastro-intestinal tract was emptied with calomel, and
afterward a morning saline was given for a few days. Hot packs were
administered, one a day for about two weeks. The patient was instructed
to drink as much water as possible, and we eliminated sugar, bread and
the 20 per cent. vegetables from the diet. The glycosuria lasted for
three days, while the vision, although beginning to improve at once
after treatment, took five weeks to return to normal. The patient was
kept in bed for three weeks. How long the glycosuria had been present
before admission to the hospital we do not know. The transient
glycosuria group without the eye manifestations required very little
treatment. They also showed a transient hyperglycemia. A carbohydrate
free diet very rapidly cleared up these cases. After a time we decided
to watch the course of this group on a non-restricted diet, even with
sugar, and we found that they all returned to normal (blood and urine),
in a few days clearly indicating their transient nature. We do not
regard this process as a diabetes mellitus. We do not give the hot
packs, although free elimination by bowel was attained in all. These
cases were recognized only through routine urine examination.
Furunculosis with a high blood sugar, in one case 0.41, without
glycosuria was a very interesting complication. We saw a great deal of
furunculosis, always with the increased blood sugar from 0.2 to 0.3, but
never with glycosuria. Reducing the carbohydrates, or even a fast day
with good intestinal elimination, had excellent results.
Neuritis and general debility have often been associated with nasal or
tonsilar infection, which when surgically corrected led to the
disappearance of symptoms and improvement of health.
Finally, we wish to refer to an isolated case of acute osteomyelitis
which was incised, and from the purulent fluid present in the bone B.
influenzæ was grown in pure culture. This is a very unusual
complication, and is of particular interest on account of the positive
bacteriological finding. The patient made an uneventful recovery.
McGuire and Redden Jour. A. M. A., 1918; lxxi, p. 1311.
McGuire and Redden Jour. A. M. A., 1919; lxxii, p. 709.
Brown and Sweet Jour. A. M. A., 1918; lxxi, p. 1565.
Ross and Hund Jour. A. M. A., 1919; lxxii, p. 640.
Spooner, Scott and Jour. A. M. A., 1919; lxxii, p. 155.
Heath
Maclachlan and Fetter Jour. A. M. A., 1918; lxxi, p. 2053.
Heist and Cohen Jour. Immunol., 1918; iii, p. 261.
Kyes Jour. Med. Res., 1918; xxxviii, p. 495.
[Illustration]
THE PREVENTION OF EPIDEMIC INFLUENZA WITH SPECIAL REFERENCE TO VACCINE
PROPHYLAXIS
By SAMUEL R. HAYTHORN, M. D.