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PNEUMONIA AND SOME OF ITS COMPLICATIONS AT CAMP BOWIE

PNEUMONIA AND SOME OF ITS COMPLICATIONS AT CAMP BOWIE PNEUMONIA AND SOME ITS COMPLICATIONS OF AT CAMP BOWIE GREENWAY JAMES C. (New Haven, Conn.) M. U. S. Major, C., Army CARL BOETTIGER (New York) M. U. S. Major, Army C., HOWARD S. COLWELL (Worcester, Mass.) M. U. S. Captain, C., Army The cases of 2,344 and the various at the pneumonia complications base at Bowie be into hospital three Camp may periods. grouped Period the of the base opening 24, 1.\p=m-\From hospital, Sept. 1917, to 1918: 1, this occurred an of Jan. During measles, period epidemic with incidence of followed numerous serious large pneumonia, by and death rate. complications high Period 2.\p=m-\From to 27, 1918: The first three and a 1, Jan. Sept. half months of this continued to show a incidence of period high pneu- the number and of the was monia, not though severity complications as as in Period 1. From 15 27 to was a com- great April September paratively quiet period. Period 3.\p=m-\From to 1919: This 28, 1918, 1, Sept. Jan. period included a incidence a of influenza and of very high high percentage In contrast to the of there were com- 1917, pneumonia. pneumonia few and these were of a less virulent paratively complications, type. PERIOD 1 were cases of measles 1* There 3,624 Period during (Chart 1). In to a addition the measles there was infection of the widespread tract the There were 973 cases upper camp. respiratory throughout and in 363 of these could we obtain a of of only history pneumonia, month measles within a the of the preceding development pneumonia. in a number the there have been of cases of may camp During epidemic in abortive at the which measles, time, unrecognized pneumonia later. developed in all charts and tables are as of date of Figures given and admission, not of or of diagnosis development complications. Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 237 a There were deaths these cases, among pneumonia mortality of 24.4 cent. In 17 cent, of the cases per (Chart 2). per pneumonia with a of 32.5 cent. empyema developed, mortality per will seen 1 that was reached It be from Chart the first not peak a much until two weeks after the of the measles beginning epidemic, than in case the There time the of influenza was then longer epidemic. a diminution in the number of but the arrival of 6,000 cases, following a as draft second almost occurred two weeks after troops, peak, great, was the first. There a decline for ten when thereafter, steady days the admissions ceased. gradually The does follow of so as curve not that measles pneumonia closely in The first the later influenza followed epidemic. pneumonia peak the first measles ten six after the second measles peak by days ; days there was a rise in the number of cases of peak pneumonia. TABLE 1.—Bacteriology of Pneumonia During Period 1 6-15, 1917) (Dec. Examinations Made Found Organisms No. of Percentage Cases of Cases Dee. 1917 6-15, cases_ Sputum: 62 Pneumococcus I. 22 35.5 Type II Pneumococcus II. 0 Type Pneumococcus II 9 14.5 Type atypical.. Pneumococcus III. 2 3.2 Type Pneumococcus IV. 29 46.8 Type Pleural fluids: 17 eases. 13 76.0 Hemolytic streptococcus. Pneumococcus II 2 12.0 Type atypical.. viridans. 2 Streptococcus 12.0 cultures: 30 cases.. 18 Lung Hemolytic streptococcus. Postmortem Dec.15-31, 33 Pneumococcus I. Sputum: eases. Type 27.» Pneumococcus TypeII. 7 21.1) Pneumococcus III. I Type 3.0 Pneumococcus IV. Group 13 3il.ll Pneumococcus IV and Hem. Group 2 6.0 strep. Hemolytic 3.0 streptococcus. data included in this were Bacteriology.—The bactériologie period furnished the Red Cross Car with Drs. "Metschnikoff," by Laboratory and Maxwell and which was Dochez, sent to this Jobling Captain in assist to the base camp December, 1917, early hospital laboratory, manned to at that time and do the insufficiently equipped necessary work. After Dec. the base made routine 15, 1917, hospital laboratory determinations the method mice type by glucose-blood-broth (white were this not The results of work are shown in Table 1. available). The of infection with is indicated prevalence hemolytic streptococci by its incidence in the fluids and direct cultures. high pleural lung PERIOD 2 and there was a incidence of 1918, During January February, large the clinical a of lobar pneumonia, variety showing greater percentage and little from the seen in civil life. pneumonias differing very variety Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 I constituted 26.5 of cent, the whole number. Type pneumonia per March 15 and 117 cases of Between were 15, 1918, April pneumonia admitted to the 10 of these hospital, (8.5 per cent.) showing Strepto¬ in the The coccus cases to hemolyticus sputum. Type dropped 13.6 IV cent, and showed 69.2 cent. per Group per pneumococcus and cases an Between March 26 349 of acute 13, April respiratory infection were admittted. These were called "influenza" because not of lack of a for such bactériologie support diagnosis. Clinically, they resembled the condition called influenza, closely subsequently although this is diagnosis questionable. the latter half of a in 1918, number of recruits During June, large the Detention severe bronchitis. from Camp developed Sputum twenty more cases was to of the severe submitted the for examina¬ laboratory tion. In cultures made from 60 con¬ addition, were nasopharyngeal tacts with these cases and from 60 chosen at random, men, throughout the camp. : The washed three times in saline was Method.—Sputum sputum emulsified in then in dextrose-blood-broth. After and broth, planted were six to hours' human streaked incubation, eight blood-agar plates from these cultures and were studied after twelve to hours' eighteen and after hours' incubation. Pneumo¬ incubation, again forty-eight colonies were fished into dextrose-blood-broth cul¬ coccus and pure for tures submitted to the test bile and with solubility agglutination serums. Colonies wide area of and type showing hemolysis having characteristics of were considered morphologic streptococcus hemolytic streptococcus. : was cultures The swabbed for as Naso-pharyngeal naso-pharynx carrier detection. Swabs were into meriingococcus placed immediately were broth and from human blood tubes, these, agar plain plates streaked and incubated to hours. Plates were twenty-four thirty-six then studied for of colonies. such as types Organisms staphylococci and Micrococcus catarrhalis not recorded. Results are were given in 2. Table TABLE Found 2.—Organisms in Sputum and Nasopharyngeal Cultures from Camp and from Detention Number of Normal Equal Controls (June, 1918) Naso-Pharyngeal Sputum Present Contacts Organism Cases Per Cent. Cases Per Cent. Cases Per Cent ¡ I 21.1 II HI Hemolytic streptococcus. Pneumococcus I. 3 15 Type Pneumococcus IV. 15 75 Group over. 75 30 50 Hemolytic streptococcus, 14 23.2 Pneumococcus over. 75 7 14 2 undetermined, 3.3 Pneumococcus and Hem. 13 streptococcus. 3 5.0 Neither nor pneumococei streptococci... « 75.0 Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 *. ·» i8 I* S «I %*»/ %tíí %¿f ¡¿et v>? %as ì'.tì "À ti *- / ri lu a* so ?nis ¡lililí -rm-r TW iiiiii ñ. n s ti m Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 of the remainder Period after 2, the During especially Thirty-Sixth in Division left there were cases of July, only forty-three pneumonia with deaths. the two Nine of the showed forty-three hemolytic strep¬ tococcus in the a infection and two were mixed predominating sputum, of and IV pneumococcus. hemolytic streptococcus Group Of the 538 a of pneumonia patients, only forty-eight gave history antecedent infection within a an month. In the of great majority instances there was a definite of insufficient history clothing,. exposure, or followed which have been overheating, by injudicious cooling, may the factor in the onset. precipitating The total for this was 7.4 there mortality cent., period per being fatalities the 538 cases. among forty Fifty-two patients (9.7 per cent.) 37.5 and cent, of the total deaths. developed empyema per provided is that in all the lobar cases Bacteriology.—It significant pneumonia were in the and found ten of the fatal sputum, pneumococci eighteen cases reacted to serums II. and specific Hemolytic type streptococci were an in still factor and three of nine important (Table 2), purulent this was in addition to the pleurisies present pneumococcus. organism month the of there occurred four of interstitial cases During April caused the These cases bronchopneumonia by hemolytic streptococcus. occurred the time the small acute at of of infec¬ epidemic respiratory tion described. previously PERIOD 3 of The the on 17 Influenza. development epidemic September with the admission of cases of a not uncommon of began type upper tract infection, about five before the respiratory numbering daily, semblance of an was evident. On 26, epidemic September twenty-four cases were of influenza admitted. the which con¬ During epidemic tinued Nov. cases of were to 15, 1918, this infection admitted to 3,876 and the base Six hundred cases were held in the hospital. thirty-four observation of wards the Detention Camp. in Blood of the table of blood counts (Table 3) Counts.—Study that influenza shows the first five weeks, repre¬ uncomplicated during the of incidence, the number of counts senting period highest largest were below the below 10,000; was and polynuclear percentage seventy, the was over As the of the lymphocyte percentage twenty-five. severity the total counts were and the white declined, epidemic higher, poly¬ were increased. The same tran¬ nuclear percentages correspondingly sition is in the influenza apparent pneumonia following (Table 10), of is than in the uncom¬ the counts percentage high greater although cases. plicated Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 TABLE 3.—Blood Counts in Uncomplicated Influenza Cases (Based on 400 Counts Made During the First Five Days of the Disease) Sept. 1918 Oct. 1918 Nov. 1918 25-30, 1-31, 1-30, Cases Per Cent. Cases Per Cent. Cases ; Per Cent. Total counts. 49 212 139' I.o Under 8 1 5,000. 3,0 23.5 'si 70.0 Kit 05.0 5,000-10,000. 12 00 Over 24.0 32.0 105 75.5 10,000. Differential counts. 29 155 120 Polymorphonuclear neutrophils Under 50 cent. 1 3.5 3 2.0 per 50-70 cent. per 15 51.5 07 43.0 43 34.5 71-85 cent. 41.5 82 per 12 S3 53.5 05.0 Over 85 3.5 per cent. 1 2 1.5 1 0.5 Lymphocytes 10-25 cent. 31.0 07 43.5 02.5 per 00.0 25-50 cent. 85 54. 37.5 per Over 50 cent. 2.0 per was common under not a Leukopenia (counts 5,000) finding, absence of was the rule. though leukocytosis This in was a the blood with some¬ change findings synchronous what clinical The reached its in changed picture. epidemic peak numbers seven in and at the end of the second week the days, severity the of infection was as shown a less decreasing, by profound prostra¬ diminished tion, malaise, less and milder toxic general frequent more and convalescence. erythema rapid Reference to Chart 3 shows that the first of the influenza peak that of the five The second occur¬ precedes pneumonia by days. peak, three weeks coincident with later, the arrival of the first incre¬ ring ment of drafted from the second of Missouri, troops precedes peak the seven There were received the detention at pneumonia by days. the of the drafted white men course 4,108 and camp during epidemic drafted colored men. 2,360 the white 252 thousand men who men, were Among per exposed the 114 thousand infection, Not developed per pneumonia. developed a an of antecedent influenza every pneumonia patient gave history infection. 795 cases a the of of influenza Among pneumonia, history month was within the obtained in 728. preceding No deaths attributable were to influenza. The total uncomplicated deaths in the 833 cases of numbered a of pneumonia, 156, mortality 18.7 cent. men per and Thirty-six (4.3 per cent.) developed empyema furnished 11.5 of cent, the total deaths. per in the It is that of rate for interesting spite higher morbidity influenza and black the among pneumonia troops, mortality percentage them was somewhat less than of that the white (17.1 per cent.) among troops (20.8 per cent.). From Chart 2 it would at first that the appear highest mortality reached after the onset of the the virulence of was quickly epidemic, infection thereafter and the the from decreasing mortality diminishing Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 21.2 and 19.1 cent, to 12 and 9.1 for semi¬ per per cent., respectively, true is That this have been evidenced monthly periods. may partly by the fact that the admitted after the first weeks did not two patients so ill. of to be That the virulence the appear infecting organ¬ severely ism is shown the incidence and of persisted by mortality pneumonia the Missouri drafted who arrived three weeks after the among men, in of the was reached. These men arrived from peak epidemic camp 22 to 25. were October October overtaken influenza October They by and to November 23-31 October 28 4. developed pneumonia Among them there 199 cases of with deaths, developed pneumonia thirty-nine a the almost to that at (19.6 per cent.) mortality equal occurring half of the The lower total for the first height epidemic. mortality of November was due to the inclusion of scattered cases ninety-one that had been in these occurring among Among troops camp longer. cases were a 12 there eleven of cent. deaths, per only mortality were routine swabs 25, 1918, Bacteriology.—Sept. naso-pharyngeal made in all cases admitted with the of influenza. In all, diagnosis were examined cases seventy-five satisfactorily. Method : Swabs were from as described made the naso-pharynx in "Standard Method for Carriers for U. S. Meningococcus Army." human These were first streaked on and afterward blood-agar plates, in immersed The latter cultures were incubated glucose-blood-broth. about six hours were and human then streaked blood-agar plates from them. Identification: and "Standard Method by Streptococci pneumococci for S. that of other work identifica¬ U. Army," press except prevented were tion of of Plates incubated to types pneumococci. eighteen hours. Influenza bacilli when found in were twenty-four quantity in in characteristic this time. The are shown results growth present in Table 4. TABLE 4.—Bacteriology of Naso-Pharyngeal Cultures in Influenza Number Per Cent. over 75 34 45 Hemolytic streptococci (colonies per cent.). Associated organisms: Pneumococci 18 (type undetermined). . 19 Staphylococci Gram positivebacilli. 3 Unidentified undetermined over 75 26 35 Pneumococci, type (colonies per cent.). Associated organisms: Hemolytic streptococci. . 2 Nonhemolytic streptococci . 11 Staphylococci Micrococcus catarrhalis . 1 Influenza bacilli 7 9 present. Associated organisms: Hemolytic streptococci. Pneumococci undetermined). (type Micrococcus catarrhalis. . 4 Staphylococci over 75 cent.). 10 Nonhemolytic streptococci (colonies per Associated organisms: . 6 Staphylococci Micrococcus . 2 catarrhalis Friedländer bacilli. 1 Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 t. "Prie moma, "TLjpes jjo-etertcTAo^GcCA -2 3cLSadL +í or\ \Q(^0 Spu^wrn Cxo¡jvu¿q^iJx\s = of Columns Number _ICW/wT* Sputo. I % TLjpe -. °/o f^peTE ti TSE Type Croup Streptococcus (E -ß -80 J* -\ -éí ^A ^fl· ^â± -4l· --40- ^^ -3& -ê^ -e± ./' *e ^s- Si tzxi -*« ^'- 7>--. ñ -~4 '¿s | . ç*b K\cr Apr June o¿t Nov Pec Julvj &>s Sept Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 : Postmortem The Period as Bacteriology bacteriology during 3, determined cultures and incidence of in the the by lung complications of three lobar of types cases, (1) pneumonia, (2) bronchopneumonia the confluent lobular and of the inter¬ type, (3) bronchopneumonia stitial is shown in Tables 6 and 7. The the 5, type, group showing interstitial of and the of type pneumonia highest proportion complica¬ showed in 64 tions, cent, of per cultures, hemolytic streptococcus lung as our with just experience streptococcus pneumonia complicating measles had led us to expect. TABLE 5.—Bacteriology of Lobar Pneumonia as (Twenty-Four Cases) Determined by Lung Cultures Cases Not examined.. 8 alone. Pneumococcus, Type II, 1 Pneumoeoecus, Group IV, alone.. IV and Pneumococcus, Group influenza. 2 and 1 Pneumoeoecus, Group IV, influenza nonhemolytic streptococcus. Pneumococcus, undetermined, alone. 3 type undetermined and influenza. 1 Pneumococcus, type undetermined and Mierococeus catarrhalis. 1 Pneumococcus, type Influenza 25 bacillus, 4 cases; per cent. Per Cent. Complications Pleurisy, purulent. 12.5 fibrinous. 30.0 Pleurisy, Pleurisy, serofibrinous. 12.5 serous. 8.0 Pleurisy, Meningitis,purulent. 12.5 Substernal 4.0 pus pocket. Lung 4.0 abscess. . 4.0 Peritonitis, purulent brain. 4.0 Edema, duration disease Average of 9.2 days. TABLE 6.—Bacteriology of Bronchopneumonia—Confluent Lobular Type (68 Cases) Cases Not examined 17 Pneumococcus, type undetermined, alone. undetermined and influenza. 5 Pneumococcus, type undetermined and catarrhalis. 1 Pneumococcus, type Mierococeus alone. 14 Pneumococcus, Group IV, IV and influenza. 1 Pneumococcus, Group III,alone. 1 Pneumococcus, Type . 2 Pneumococcus, Type I, alone. Influenza and M. catarrhalis. 1 alone. 2 Hemolytic streptococcus, Hemolytic and IV. 1 streptococcus pneumococcus, Group alone. 11 Nonhemolytic streptococcus, and influenza.. 1 Nonhemolytic streptococcus Bacillus of alone. Friedländer, 1 3 6 cent. Hemolytic streptococcus, cases; per Influenza 8 bacillus, cases; 16 per cent. Per Cent. Complications Pleurisy, purulent. 4.5 serofibrinous. 11.0 Pleurisy, fibrinous 23.0 Pleurisy,. serous.. 4.5 Pleurisy, serofibrinous and 3.0 Pericarditis, purulent. Metastatic 3.0 abscess. disease duration of 8.5 Average days. Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 in the bacilli were found 16 cent, of Influenza per in and and 25 cent, of the lobar per pneumonias, bronchopneumonias associated with other always organisms. lobar cases the was found. In all of the pneumonia pneumococcus cases of confluent In the the lobular bronchopneumonia type, thirty- five IV per pneumococcus, (70 cent.) yielded pneumococcus Group or undetermined, nonhemolytic streptococcus. type from blood cultures were made heart's Satisfactory postmortem in as in with results shown Table 8. cases, eighty-one Table 7.—Bacteriology of Bronchopneumonia—Interstitial Type (33 Cases) Cases Not examined. 11 alone 10 Streptococcus, hemolytic,. and IV. Streptococcus, hemolytic Group 1 pneumococcus, and Streptococcus, hemolytic pneumococcus, undetermined. 2 and influenza. Streptococcus, hemolytic 1 Streptococcus, alone. 1 nonhemolytic, and influenza. 1 Streptococcus, nonhemolytic alone. 1 Pneumococcus, undetermined, undetermined and Friedliinder bacillus. 1 Pneumococcus, alone. 1 Pneumococcus, Type III, alone. 3 Pneumoeoecus, Group iV, fi4 cent. Streptococcus, hemolytic, 14 cases; per Influenza cases: 9 cent. bacillus, 2 per Per Cent. Complications Pleurisy, purulent.-. 40 serofibrinous 18 .. Pleurisy, fibrinous. 28 Pleurisy, serofibrinous and 9 Pericarditis, purulent. . 9 Peritonitis, purulent Substernal 9 pus pocket. Metastatic abscess. 3 abscess. 6 Lung duration of disease 14.5 Average days. of Cultures from TABLE 8.—Bacteriology Heart's Blood (Postmortem) Total cultures. 81 No. 19 growth undetermined. 19 Pneumococcus, type GroupIV. Pneumococcus, Type 1 Pneumococcus, II... 2 Type. Pneumococcus, III. Pneumococcus, Type hemolytic. 11 Streptococcus, Streptococcus, nonhemolytic. cases of lobar have cases, Diagnosis.—Certain especially pneumonia, in the offered no In those difficulty diagnosis. secondary pneumonias, in measles in and those influenza 1917, especially following following was so it the rule rather than the for the to be 1918, exception signs as to offer the in not to as irregular greatest difficulty diagnosis, only evidence of but as to the clinical the consolidation, especially variety. these have all shown The from cases practically sputums streptococcus, or a mixed infection. IV, pneumococcus Group Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 How we have failed in the differentiation of the clinical badly types of under the conditions be seen here, pneumonia existing may by reference to Chart 8. In and October the November, measles 1917, during epidemic, there were 626 cases came of of which to pneumonia, fifty-five these lobar was necropsy. cases, Among fifty-five pneumonia diag¬ in as in nosed fourteen, two per correctly bronchopneumonia (14 cent.). was in as cases, lobar Bronchopneumonia diagnosed twenty correctly in cases per cent.). pneumonia twenty (50 Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 In influenza and 1918, the October, epidemic, September during to there were 714 cases of of which 122 came necropsy. pneumonia, these Of 122 were lobar cases, eighteen diagnosed correctly pneu¬ fifteen were called monia, bronchopneumonia (45 per cent.). wrongly nine- were as cases ; properly diagnosed bronchopneumonia Eighty-one cases were called lobar There teen pneumonia (19 cent.). wrongly per for these were certain circumstances wrong diagnoses. extenuating the was at table differentiation Even the frequently postmortem The fact remains on clinical differentia¬ that statistics based puzzling. between lobar seen this tion and at bronchopneumonia hospital during existence not the first months of its are reliable. For this sixteen Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 reason we have included the differentiation in the tables and not Chart will serve as a charts, in which with 7, except comparison figures sources. furnished from other in the Onset.—As this was observed measles pneumonias following in was a difference in and those influenza, there the following great two In 1917 an it took for acute infec¬ epidemics. apparently longer tion of the tract to into a A upper respiratory develop pneumonia. of an infection several before acute weeks the history existing pneu¬ was monia often obtained. In the pneu¬ developed post-influenzal the of consolidation later than five monias, signs rarely appeared days after the initial of the the duration of the febrile symptoms influenza; two most of influenza been to five often three. period having days, were The infections both of the des¬ following epidemics usually some the involvement In cases of the and cending type. lungs pleura almost it doubtful whether the con¬ appeared simultaneously, leaving solidation or came In the first. the empyema 1917, especially, pleural involvement was often the initial and feature the outstanding ; pain the was the face the features intense, extreme, flushed, prostration fluid formed before of con¬ drawn and (usually streptococcal) signs were cases solidation manifest. In the of and chill did majority pain not in the onset. The increased and figure temperature, high pulse increased were indications for careful and rate respiratory frequently examinations. repeated physical 1 2 and cases were seen in which the During periods occasionally of ushered in the infection. the signs meningitis Usually, meningeal for about then the first of hours; signs persisted twenty-four signs consolidation would fluids were appear. Spinal negative. cases in the of these difficult Signs.—The physical signs majority were and frank. Dulness, extremely irregular rarely suppressed often moist at the of breath râles, sounds, crackling especially height or even a in the of the breath and voice inspiration, change quality the the sounds—one or more of but were bases of these, all, rarely In the absence of evidence—such as the subse¬ diagnosis. supporting course of the counts and disease, quent leukocyte roentgenograms of an these cases would not have been It was not many diagnosed. to have the frank follow several infrequent experience signs days in after the decline of and the temperature improvement general condition. cases in Lobes Involved. Of which the first involvement 1,533 affected one the lower lobe was first noted lobe, involved in right only 711 in 679 in the left lower lobe the lobe 54 cases, cases, upper right the in in left lobe 48 and the middle lobe 41 cases, upper cases, right In a number of the cases of associated with cases. large pneumonia Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 the influenza the initial involvement was simultaneous in epidemic, lobes. It is of in four both lower anatomic interest to note that an on additional lobe was observed twice the left and twice necropsies on the side. right 2 the Blood Counts.—In Periods 1 and blood counts were such as encountered in are the first five pneumonia. During ordinarily days of the disease about 85 cent, of the total number of white counts per the made over and in the same of cases was 10,000, proportion poly- nuclear was 70 or over (Table 9). percentage TABLE 9.—Blood Counts in Pneumonia Period 1 Period 2 Period Influenza 2—Following Sept. 25- Jan. 1- Dcc. ! 1-31 31, Sept. 27, Sept. 28-30, Oct. 1-31, Nov. Cases Per Cases Per Casesi Per Cases Per Cases Per Cent. Cent. Cent. Cent. Cent. Total Counts: first five During days- Under 2 10 5,000. 4 10 6 12 5.000-10,000. 12 3S 79 (¡0 7 Over 13 S4 16 51 41 31 10,000. After five days— 19 1 43 24 30 5,000-10,000. Over 18 SI ß 57 70 100 10,000. Differential Counts: Polymorphonuclears- 50-70 cent. 10 2 5 25 43 2 per (14 70-85 cent. 21 53 17 75 54 19 per Over 85 cent. 25 L9 42 3 2 per .. When are the for these two with those figures periods compared for Period it will be noted are 3, that reversed they very nearly 60 cent, of these counts under while in 35 cent, per 10,000, being per the was below polynuclear percentage seventy. It is not unreasonable infer that the failure of the individual to to react to his with a at this time is evidence of pneumonia leukocytosis a diminished resistance influenza. In the this produced by preceding in connection it is to note that of made counts interesting thirty-one cases in no was which antecedent of influenza history present during Period 3, were over and 10,000 15,000) twenty-seven (average only four were below Also that the duration of illness in 10,000. average the fatal cases first two was while in twenty-one during periods days, the last was it eleven period days. Blood Cultures.—Oí 254 blood cultures taken satisfactory during or in life, 13.8 cent, were Of the 219 per cases thirty-five, positive. which sterile blood cultures or 11 were obtained, twenty-four, per cent., of the whereas of the cases with died, blood patients thirty-five positive Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 cultures or fourteen 40 died. This is in accord with per cent., patients, that the view a blood culture life makes the positive during prognosis grave. Examination Chart 6 shows Bacteriological of Sputum. type the cases determinations for 1918. Of the 1,371 of year pneumonia in in the or 79.5 was 1918, 1,090, occurring sputum cent., typed. per From Dec. III serum was obtain¬ 28, to 20, 1918, not 1917, Jan. Type IV III able for this include some ; therefore, may Group period Type cases. the four winter months—December, During January, February and March—the of incidence of was 23.8. The percentage Type was incidence the of weather 5.9 cent. With period per during good II the winter months showed an incidence of 11.1 cent.— Type per the summer months 3.1 In the decreased inci¬ cent. contrast to per of dence these fixed IV 61.9 shows Group pneumococcus per types, in winter and summer months. cent, the months 69.2 cent, in the per curve The includes both and streptococcus hemolytic non-hemolytic and resembles the IV in its curve variations. streptococci, Group TABLE 10.—Pneumonia : Cases and Mortality on the Basis cf 1,090 Sputum Type Determinations Cases Deaths Mortality, Cent. per Pneumococcus I. 7 4.9 Type Pneumococcus II. 14 20.0 Type Pneumococcus III. 45 13.3 Type Pneumococcus IV. 722 75 10.4 Group Pneumococcus TV 25 6 24.0 Group and Hemolytic strep. 5 5 100.0 Nonhemolytic streptococcus. . 11 13.3 Hemolytic streptococcus. the The in various of as mortality infecting types organisms, determined is shown in Tables 10 and 11. examinations, by sputum note the in It is to variations for the same in interesting mortality type different All with the of showed periods. types, exception III, Type a Period much 3 the influenza higher mortality during (accompanying than had shown the first nine months of the epidemic) they during year. TABLE 11.—Periods 2 and 3. Mortality of Various Types of Organisms Compared Mortality Mortality Percentage, Percentage, Oct.-Dec. Jan.-Scpt. Pneumococcus I. Type 7.4 Pneumococcus II. Type 37.5 III. Pneumococcus Type 12.5 Pneumococcus GroupIV. 12.0 and Streptococcus—hemolytic nonhemolytic 23.0 at this has shown that to limit the Experience hospital investiga¬ to tion of a determination of the of pneumococcus sputum type present, Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 a as does not reliable to the nature of the always give guide existing infection. We need call attention to a of our only comparison sputum in fluids and with the found determination, type bacteriology pleural 1 to It at Period illustrate this necropsy, during (Table 1) point. seems to to determine the attempt necessary predominating organisms. been to this from a differential count of Our has estimate practice on human streaked colonies from either first culture blood-agar plate in the or from the of mouse. glucose-blood-broth peritoneal cavity in the the with the other Comparing findings sputum bactériologie in same such as from the examination of blood the case, findings should furnish cultures, fluids, cultures, necropsy, etc., pleural lung the best evidence as to their value in Such a ordinary hospital practice. is made in Table 12. The of comparison correspondence percentage is conditions into consideration the under which the work high, taking and was indicate that this should remain one of our done, procedure the routine methods for of diagnostic study pneumonia. TABLE 12.—Comparison of Sputum with Other Bacteriologic Findings With Other Bac¬ Corre¬ Per Dif¬ Per Sputum Cent. ferent teriologic sponding Cent. Findings Pneumococcus I. 7 5 71 2!) Type tí Pneumococcus II. 12 50 50 Type 1 S4 Pneumococcus III. ß 1« Type Pneumococcus IV. 74 54 34 16 Group 17 13 7fi 4 24 Streptococcus, hemolytic. 4 75 1 Streptococcus, nonhemolytic. con¬ Course.—The toward a fatal termination varied progression as in those cases in the fall of contrasted 1917, siderably occurring in the fall of 1918. In the former an extreme with those period anxious with all the hoarse, facies, accessory cyanosis, barking cough, of a fearful of what muscles in use, picture respiration presented was seemed the horror of death. In there little 1918, comparatively in the infections death was of this. Even streptococcus preceded by a much more This true in the of the was case quiet period. especially were none in in remained camp 1917). negroes (there They usually with shallow and met death respirations, quietly. quiet in 4 the deaths the Chart shows two occurring epidemic periods with reference to the duration of the illness. the Accompanying it is an number for measles the first always increasing week, epidemic the and after second week. the influenza the second week During in the number in the first week is than that epidemic dying greater and the least number survive more than the second week, days. Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 TREATMENT OF PNEUMONIA in serum been used all I Serum has Type Therapy.—The specific of those which had defervesced at the time cases, except practically determination. type The time between the to the and the sending sputum laboratory the serum twelve the of was to hours, during giving eight except of all when the stress of work the prevented desensitizing epidemic, as was as soon the made. pneumonia patients diagnosis There were 142 infections. One hundred and 1918, during Type were treated with died mor¬ serum; seven twenty-five patients seven while of 5.6 cent. Four of these deaths, per tality (Table 13). were to caused charged pneumonia, really by empyema, twenty-nine, and fifteen after the twenty-eight, twenty-four days, respectively, these of the the mor¬ deaths, pneumonia. Eliminating development cases 2.4 of the treated would be cent. per tality TABLE 13.—Complications Cases Per Cent. Total Recognized Recognized Cases at Only at Only Necropsy Necropsy 28 11 Empyema. with effusion. 101 Pleurisy Otitis media—suppurative (22 bilateral). media—catarrhal 40 Otitis (13 bilateral)_ Mastoiditis (2 bilateral). 24 58 Pericarditis. 17 18 abscess. Metastatie Emphysema, subcutaneous, generalized.. 10 100 mediastinal tissues 10 Emphysema, only.... abscess. 9 Lung 2 17 Meningitis. 8 «7 Peritonitis. 7 100 Substernal pockets. pus Thrombophlebitis. chronic Nephritis, parenchymatous. toxic. 18 acute Nephritis, Sinusitis. Myocarditis. Toxic psychosis.— I untreated. None of these Seventeen infections were Type were most those The untreated for the died. patients part patients or in of their sent because of the mildness infection, who,' delay being of infection could into the had their crisis before the the type hospital, determined. A few of these were sensitive to horse serum, be patients treated because were not sick. but were not very they and results have followed the administration of No serious serum, our a for its use. The we feel that is experience strong argument more are the results obtained. This is earlier it is the used, striking of defervescence shown in Chart which the relation of the 5, gives day on which treatment to the serum was begun. day Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 as soon as received in doses Digitalis.—All patients digitalis large the was made. In Period when a standardized tincture 3, diagnosis was was administered in obtained, it therapeutic dosage. General Measures.—Treatment other than that referred to already was symptomatic. Gross : The first cases to Pathology.—Period coming necropsy in showed the well lesions of acute November, known, 1917, typical lobar Of the first cases two showed effu¬ pneumonia. eight pleural sions one serofibrinous and the other purulent. TABLE 14.—Relation of Pleural Exúdate and Sputum in Sixty-Eight Cases of Empyema ! Percentage Cases Deaths of Mor¬ tality 1. Pneumococcus in both and sputum pleural fluid. 32 19 2. in both and Hemolytic streptococcus sputum pleural exúdate. 33 3. and in both Pneumococcus hemolytic streptococcus and exúdate. pleural 30 10 33 sputum in 4. Sterile empyemas, pneumoeoecus 3 0 0 sputum. Total. more As measles became and as both the incidence and prevalent, of the More lobes were mortality pneumonia rose, picture changed. involved. Instead of firm and the affected feeling airless, uniformly or tissue felt and distinct could be nodular, "shotty," crepitation elicited between the firm nodules. Fibrinous over the deposits pleural surface constant were more and more extensive. On the section, cut surface of mottled a dark, lung presented usually appearance, bluish-red with small elevated red background, many slightly grayish each of the a or near areas, bronchiole, at its presenting opening In cases center. these areas were confluent. The interlobular many were visible, the lobe into number of septums distinctly dividing areas. Abscess formation, small irregularly shaped especially multiple was abscesses, found. occasionally Effusions into the became and pleural cavity increasingly frequent, were visceral Adhesions between the and usually purulent. parietal often the into two or more occurred, pleura dividing pleural cavity distinct the most site of such compartments. Perhaps, frequent costal adhesion was between the anterior of the and the edge lung or the inner surface of the sternum sac. Here margin, pericardial were at times divided transverse bands formed, elongated pockets by into which contained thick two, and masses of fibrin. greenish pus Adhesions lobes with formation of between the interlobular abscesses were also found. Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 in cases. In some The was involved instances pericardium many surface a fibrin the external showed of thickness only deposit varying with and adhesion to ribs and left In sternum, organization, lung. other inner surface was with a fibrin the dull, covered instances, rough and the contained a amount of serofibrinous sac or deposit, large in which were found. fluid, purulent hemolytic streptococci TABLE IS.—Procedure in Empyema Method Period Period 2 Period Total Mortal¬ of Aspira¬ 1 3 tion Cases Treatment ity per Cases Deaths Cases Deaths Cases Deaths Cent. No. 21 20 23 3 7 71 Aspiration alone 3 2 75 20 20 27 121 10 2 8 20 10 3 4 0 io 10 2 1 1 1 4 0 Costateetomy 1 0 preceded by 2 0 aspiration 0 1 0 10 1 11 5S 2 3 Thoraeotomy 3 1 75 preceded by aspiration 5 100 Costateetomy Thoraeotomy Aspiration Mortal¬ Mortal- Mortal- Mori al- Cases Deaths Cases Deaths Cases Deaths Cases ity per ityper ityper ityper Cent. Cent. Cent. Cent. Period 1* Oct. 1- 67 0 Dec. 31, 44 Period Jan. 1- 0 10 21.3 Sept. 43 27, Period 27- Sept. 25.(1 33 24 Dec. 31, 100 38 221 Total 23 had no before death. Two cases included in totals for aspiration only aspiration (2 deaths) cases was that The in these Microscopic. microscopic picture as interstitial The illustrations described MacCallum1 pneumonia. by MacCallum, W. G.: Pneumonia at a Base 1. Cole R., and Hospital, A. M. A. 70:1147, J. Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 show some of the constant peribronchial consolidation, findings of interstitial and extensive involvement tissue, fibrino-purulent pleurisy. a confluent lobular 1.—Section of affected with bronchopneumonia Fig. lung influenza. exúdate. following Early PERIOD 2 was found in nine¬ Of lobar pneumonia twenty-five postmortems, was teen cases of the interstitial found in type, ; bronchopneumonia, six cases. The incidence of was per purulent pleurisy high (50 cent.). six This the fact that five of the be may by bronchopneu¬ explained cases this were monia showed and hemolytic complication, streptococci as cases found in one-third of the complicating organisms following infection. pneumococcus Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 3 PERIOD were Gross distinct of cases found: (1) Pathology.—Three types lobar of interstitial the pneumonia; (2) bronchopneumonia type, lesions of which have been and described, just (3) bronchopneumonia a or of lobular confluent type. with a confluent lobular 2.—Section of affected bronchopneumonia Fig. lung following influenza. Later exúdate. the latter were more or In the all firm, cases, lungs large, moderately less nodular. areas careful could Frequently, by palpation, crepitating even a which was consolidated. be in lobe felt, apparently completely cases The was smooth and many pleural covering usually transparent, scattered small of Fine fibrin¬ areas showing subpleural hemorrhage. found in some cases in the course of the ous were deposits very early Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 In cases those which showed of the medias- pneumonia. emphysema was an beneath tinal tissues there the just usually emphysema pleura which extended the interlobular mainly along septa. Section of the was followed the of a lung by outpouring large of fluid. The cut surface was bluish amount dark, dark, red, bloody in a mottled with which varied color from brownish- areas, lighter deep 3.—Section of lesion in a case of interstitial Fig. lung showing pleural caused the pneumonia by hemolytic streptococcus. a or red to and varied in size from grayish-red, light grayish-yellow, one or two centimeters in diameter It was common to find up. very areas In of different color and in the same lobe. the lower consistency lobes these and areas were most confluent, so that at times it largest was difficult to whether or not the consolidation was say homogeneous. In such the lobes showed distinct cases, however, upper always patchy consolidation. Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 The is shown in the illustrations. microscopic picture accompanying of Its characteristic features the intense edema and were congestion of in all interstitial the marked exúdate tissues, predominance bloody the alveoli in most and the distribution of the cases, lesion, irregular nor areas different not diffuse, but at showing strictly peribronchial in the same section. of stages development 4.—Section of from a case of interstitial Fig. lung pneumonia caused the by hemolytic streptococcus. The raised not to here be whether it is desirable might question the used as to cover a condition so term drop pneumonia pathologic variable in its manifestations and Careful of etiology. reading reports from to the firm belief various leads that the clinical hospitals diagnosis in cases cannot a of be made to conform with the large percentage lesion lobar and inter- pneumonia, pathologic bronchopneumonia Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 stitial Medical have used the terms lobar men, pneumonia. generally, rather the and loosely, diagnosis being bronchopneumonia usually on a one based the of consolidation of or the whole of presence part or more lobes. In such of the made workers as Cole and his asso¬ reports spite by at Rockefeller of ciates the the of Institute, knowledge bacteriology has been rather With the with vague. pneumonia unhappy experience in in in both civil life and the the fall of pneumonia, army, especially men come in numbers of medical have contact with the 1918, large in disease in a form and of manifestations amount exceeding variety in nomenclature their If in the anything previous experience. changes can so as indicate a difference be made to in the treatment prognosis, and the to be looked much will be for, complications accomplished. in the Another would be attained varieties advantage emphasizing of The inclusion of acute the infecting organisms. pneumonia among is infectious diseases recent. It is that the comparatively probable cases in a of such medical ward is and day treating general past, yet we have entered into the of the various scarcely practice isolating types of It is as undesirable to a of "acute case pneumonia. just expose lobar an as to to "acute pneumonia," streptococcus pneumonitis" medical case to either of the above. Isolation of expose any general the various of be will types pneumonia probably practiced generally in In all well conducted such with labora¬ hospitals. places adequate be facilities there will no reason for otherwise. tory doing In it is that the must private practice average probable physician to or look the state for differentia¬ sputum municipal laboratory type as now he does for examination for Klebs-Loeffler bacilli. tion, health some will Unquestionably, departments provide specific serum, and for its administration. Such when type provide differentiations, as a of serve the will to accentuate the incorporated part diagnosis, of cross infections all the importance avoiding by using present methods of and their further prophylaxis stimulating development. it be well to do as has Would therefore, been done with "rheu¬ not, reserve matism"— the "acute lobar for those diagnosis pneumonia" are cases of which well defined epidemic pneumonia fairly clinically, I or to and due either to with its pneumococcus, serum, Type specific fixed II the of and and I, III, the term types pneumococci, apply causative "acute the whenever pneumonitis," giving organism possible, various conditions now called to the other lobar, lobular interstitial, or or terminal etc. ?2 bronchopneumonia, septic pneumonia, pneumonia on and Fox in and 2. Hamburger reporting pneumococcus streptococcus used the term infections at Camp Zachary Taylor "pneumonitis." Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 COMPLICATIONS : cases Of of 249 the 2,344 Empyema pneumonia, developed an incidence of 10.6 cent. This incidence was a empyema, per steadily for the three 9.5 4.3 one 16.5, and decreasing periods, being cent., per Period 1 41.5 furnished cent, of the total per pneu¬ respectively. and 64.6 cent, of the total cases of whereas monias, per empyema, Period furnished 35.5 of 3 cent, the total and per pneumonias, only 14.4 of the total cent, per empyemas. DIAGNOSIS difficult in certain The of in the chest is very cases, diagnosis pus on much less so in others. This the amount character, depends largely location of the and whether or it occurs or late and effusion, not early of often demands all in the course the Its recognition pneumonia. the can on aids to that be summoned. The rests diagnosis diagnosis one or more of the in condition of following: (a) Change patient; and some¬ (b) physical (c) roentgenography fluoroscopy (d) signs; a in and increase not the count times, often, though change leukocyte in the number of cells be may polynuclear helpful. Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 in the Condition of Patient: course of the ( ) Change During comes there a between five and ten time, pneumonia usually days, the when in the absence of extension of the temperature, process should with the and either rates, fall, together pulse respiratory by or the remissions crisis If this fails to and if occur, lysis. especially should be aroused. In some cases the increase, suspicion temperature falls after a number of an afternoon rise of to normal; varying days We have had cases in which was temperature begins. pus present the where the fell to normal after temperature primary pneumonia, rise 99 F. after had been and did not above until the evacu¬ again pus Where the rise in ated. Chills have been rare. tem¬ and sweating or when convalescence is must be perature slow, persists, pus always cases been the first have where Many diagnosed suspected. ultimately was raised the slow convalescence and the suspicion by presence very or of were considered most pus probable. tuberculosis The have been physical (b) Physical Signs: signs notably irregu¬ no one considers the of conditions and wonder when lar, multiplicity The fluid from sero¬ vary thin, existing. may dirty (dishwater) in as in fibrinous the exúdate, color, slightly greenish early hemolytic to a dense in some streptococcus fluids, creamy pus pneumococcic In infections. between all are gradations. In a breath our with in and voice dulness, experience change a more or sometimes diminution, sounds, frequently bronchophony the best indications for a are requesting roentgen-ray egophony, be even this limited to a examination, though may fluoroscopy. With evidence from these and sometimes aids, without, supporting no a one or times. hesitation has been felt in needle many inserting In cases has been the occa¬ hundred needled, the many mishap only was no serious sional of air into the which of entrance pleural cavity, A we is have that the precaution needle, import. particular practiced the the chest once withdrawn inner surface of is to inserted, always a area. wall before the direction in order to different changing explore The This is done to avoid the tissue. of insertion point tearing lung over area of maximum since the rule rather than the is the signs, In a cases is for the to be few marked sensi¬ pus pocketed. exception on has tiveness to locate the pus. percussion helped are but a rule is to insert the needle Often signs misleading, good if is a reasonable basis for to be Fluid there believing pus present. over was has been obtained in areas which there dulness rather than a fremitus little with friction rub and vocal and flatness, present, in voice or breath sounds. On the other areas over hand, change was fremitus which there flatness, absence of vocal and markedly Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 In diminished failed to show fluid. breath sounds, have frequently latter is that a the case the there was dense fibrinous probability serous a a with little element. after Sometimes, pleurisy, dry tap, the site small of has at of the drop pus appeared puncture following the withdrawal of the needle. use Examination: The of the has ray (c) Roentgen-Ray roentgen been of the assistance in greatest diagnosis. the the the The relation of found in fluid to organism pleural pre¬ dominant Table of the is shown in 14. The organism sputum mortality of 19 cent, in as with per pneumococcus infections, compared per in and is in cent, mixed accord with the situa¬ infections, streptococcus tion as from other reported many hospitals. Table'15 the in for all Of the empyema gives procedure periods. cases 221 to or 67.9 occurred death, 150, cent., diagnosed previous per in Period 1. Of these 150 121 were with a patients, operated on, of 34 Of the rfot cent. per twenty-nine on, mortality patients operated a cent. of 89 of the died, per twenty-six mortality Twenty-one twenty- nine died after the These men were diagnostic puncture. practically moribund time of sick withstand at the too to the shock of diagnosis, The of choice has varied with the several chiefs operation. operation section. 1 it was of the In Period surgical costateetomy, thoracotomy the done in bad risks. Of the fifteen on whom a thora¬ being patients was a 73 cent. done, eleven of died, cotomy mortality per Choice of the Time of As in most the Operation: hospitals, early was to as soon as the established. was The practice operate diagnosis was a result immediate In the very high operative mortality. strepto¬ where a coccus infections, especially purulent pleuritis developed early, meant a on the prompt operation usually collapsed lung side, operated was and the with little func¬ very consolidated, possibly opposite lung tissue These at the tioning lung remaining. operations, performed meant of the either from shock or toxemia, death, height asphyxiation. With this in was view, done second experience aspiration every day for certain and the intervals increased thereafter. period gradually transition The from the thin fluids in the commonly strepto¬ present coccus infections to a thick occurs in a variable time. pus, Frequently this has occurred in hours. Ten to twelve is the forty-eight most days interval. the it is frequent Generally speaking, longer away possible to from the acute the favorable get more the end result. infection, If, the condition these should by repeated aspirations, general improves, In be continued. the case the will become average pus so ultimately thick as to render further In a certain number aspiration impossible. is still of even cases, the condition though aspiration possible, general of the becomes the rate the patient worse, increases, pulse temperature Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 becomes with an in the Chills irregular, increasing height evening. and are rare in cases. these sweating In even with the condition of many the cases, general patient fairly the time will come when with satisfactory, operation, irrigation, a more In than continuous Period promises recovery rapid aspiration. were admitted with thick formed, too many patients pus already thick to be withdrawn a were needle. These through large patients too sick to sent the to for a justify being roentgen-ray department picture. Medical aside from attention careful to Care.—Postoperative care, and is a one. to medical Attention drainage irrigation, nutrition, largely the of cardiac stimulation, and careful examinations question frequent of the chest for of accumulation of pus, effusions, signs pericardial are most Later matter etc., the it is a of "condition¬ important points. and hikes, ing," breathing carefully graduated setting exercises, up etc. games, In our this attention can best be these opinion, given by retaining on the Medical Section or more with one patients qualified surgeons to this section for the assigned necessary operative work, irrigations and It is essential that a man filled with enthusiasm for his dressings. and of the work, technic, should receive possessed surgical necessary an such assignment. Metastatic Abscesses. Metastatic or abscess, single multiple, in seventeen cases occurred of Of these seventeen cases pneumonia. four came Five to three not accompanied empyema. necropsy, being death. before One of these cases was a small diagnosed undiagnosed in abscess the first intercostal muscle a second was a case ; perirenal abscess. The most cases were of this five cases in interesting group which a tumor was noted above the not painless just symphysis pubis, to of red and not tender The first these No. cases pressure. (Reg. 2422) was not until rounded there a tumefaction recognized appeared exactly in the about inches midline, two above the extending symphysis pubis. The was a but tumor to be distended on catheteriza- bladder, thought tion small amount of urine was One very obtained. hundred cubic centimeters of salt solution was introduced into the bladder, and the same amount was withdrawn. The tumor was still The present. pos¬ of diverticulum of the bladder was considered. was There sibility no increase in no and muscular the next temperature, rigidity. During six there was a but increase in the the size of days slight, constant, the normal meanwhile a of urine. On tumor, amount patient voiding the sixth fluctuation was obtained. An incision was made and about day 150 c.c. was of thick found between the muscle pus rectus and right Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 its Culture sheath. showed a undeter¬ posterior pneumococcus—type mined. cases same The other the except presented practically picture, was that in three the tumor slightly asymmetrical. Subcutaneous subcutaneous Emphysema.—Generalized emphysema, as a of occurred in seven white complication pneumonia, eight cases, men and one man. colored Three of these recovered. patients The onset of the to be associated emphysema appeared definitely an with severe of in one case. Hoarse¬ paroxysm unusually coughing increased ness and were the refer¬ dyspnea only symptoms apparently able to this complication. tissues in The of the but also the neck, posteriorly especially, supra- clavicular were involved in all the cases the region, eight ; interscapular was involved in four the axillae and in three region ; pectoral region ; the face in flanks in one. three; the and thighs The three who recovered had a convalescence. patients prolonged Each one a had hoarseness. examination showed persistent Laryngeal an acute which One has only laryngitis, disappeared slowly. patient since been found to have tuberculosis. pulmonary Anaerobic antemortem blood cultures sterile in in were two cases; third the case showed undetermined. they pneumococcus—type Of the cases all showed of the mediastinal postmortem emphysema connective in addition to the evident subcutaneous tissue, emphysema noted life. Petechial were in evident during subpleural hemorrhages cases. two Free air beneath the visceral the pleura, especially along was seen cases. interlobular and in two One case fissures, spaces lung showed confluent of consolidation patches having undergone softening and abscess cavities. small areas of hemor¬ produced Microscopically, were in cases as cases these in other of the rhage frequent pneumonia same period. In addition there were cases ten of of mediastinal tissue emphysema at diagnosed only necropsy. of the mediastinal tissue marked Bactériologie study showing in with the was cases results on emphysema attempted eight following culture No 3 growth. Pneumococcus IV. Group . 1 Streptococcus, nonhemolytic Streptococcus, hemolytic. in In each case the was also found the blood present organism stream. one In case with most marked subcutaneous before emphysema an emulsion of tissue death, was emphysematous injected intravenously Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 a into rabbit. The rabbit was killed in five minutes and in the placed All incubator for hours. as well as heart's blood, eighteen organs, a IV which was also isolated from the gave pneumococcus Group heart's blood of the patient. SUMMARY of the cases of here fol¬ large percentage pneumonia presented lowed an of measles and an of influenza. epidemic epidemic Following the of of the epidemic measles, predominance hemolytic streptococcus as the determined the and the infecting organism high mortality high incidence of complications, especially empyema. the of influenza the incidence of Following epidemic hemolytic when lesions was but the did not less, streptococcus present produced cases from those in of the In addition to vary year present previous. was a cases the infections there of of mixed streptococcus large group with IV, bacteriology pneumococcus, especially Group predominating. the of the to 1918, During part period, January September, greater the character of the and were not infection, mortality complications different from those the essentially occurring ordinarily. Throughout were first of this of fixed I and II part period, pneumococci Types as found in the same of cases when these approximately proportion were first described. From that time on declined types they steadily until less than five cent, of the cases showed their per presence. Definite evidence of the of a the B. as deter¬ influenzae presence factor in the of the fall of 1918 mining pneumonias following epidemic was not obtained at this The whatever its hospital. epidemic, etiology, caused of resistance which favored invasion lowering by organisms identical with those which observation had during nonepidemic periods be in the shown to tract of individuals not respiratory present upper from suffering pneumonia. Postmortem studies show that the is pneumococcus constantly pres¬ ent in lobar while the with a pneumonia, hemolytic streptococcus, in of other and the is found broncho¬ variety organisms, pneumococcus, pneumonia. of examinations with more accurate bactéri¬ Comparison sputum data from the has shown a same in ologie cases, correspondence large If the examination is made with a view to deter¬ percentage. sputum the its value is mining predominating organism present, greatly one enhanced and in this form it is of the valuable diagnostic pro¬ in cedures pneumonia. Clinical differentiation between lobar and to bronchopneumonia accord with has been For this reason postmortem findings impossible. it is that the term acute followed a state¬ suggested pneumonitis, by ment of the in the be used to predominating organism sputum, desig- Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 cases are not in but nate those of which lobar pneumonia frankly type, one caused of the fixed of by types pneumococcus. was The incidence of the fol¬ among empyema highest pneumonias measles. For the entire cases with empyema period, complicated lowing 10.6 of the total and furnished 25.6 constituted cent, per pneumonias, total deaths. cent, of the per pneumonia the The of the exúdate caused by appearance pleural Streptococcus was fol¬ characteristic. of such fluids, hemolyticus Repeated aspiration has lowed after the acute has subsided, by operation pneumonitis given more results at this the satisfactory hospital. occurrence of in The was encapsulated very common, especially pus infections. These the were frequently multiple streptococcus pockets an and offered difficulties from great operative standpoint. Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine Unpaywall

PNEUMONIA AND SOME OF ITS COMPLICATIONS AT CAMP BOWIE

Archives of Internal MedicineJul 1, 1919

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Publisher
Unpaywall
ISSN
0003-9926
DOI
10.1001/archinte.1919.00090240004001
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Abstract

PNEUMONIA AND SOME ITS COMPLICATIONS OF AT CAMP BOWIE GREENWAY JAMES C. (New Haven, Conn.) M. U. S. Major, C., Army CARL BOETTIGER (New York) M. U. S. Major, Army C., HOWARD S. COLWELL (Worcester, Mass.) M. U. S. Captain, C., Army The cases of 2,344 and the various at the pneumonia complications base at Bowie be into hospital three Camp may periods. grouped Period the of the base opening 24, 1.\p=m-\From hospital, Sept. 1917, to 1918: 1, this occurred an of Jan. During measles, period epidemic with incidence of followed numerous serious large pneumonia, by and death rate. complications high Period 2.\p=m-\From to 27, 1918: The first three and a 1, Jan. Sept. half months of this continued to show a incidence of period high pneu- the number and of the was monia, not though severity complications as as in Period 1. From 15 27 to was a com- great April September paratively quiet period. Period 3.\p=m-\From to 1919: This 28, 1918, 1, Sept. Jan. period included a incidence a of influenza and of very high high percentage In contrast to the of there were com- 1917, pneumonia. pneumonia few and these were of a less virulent paratively complications, type. PERIOD 1 were cases of measles 1* There 3,624 Period during (Chart 1). In to a addition the measles there was infection of the widespread tract the There were 973 cases upper camp. respiratory throughout and in 363 of these could we obtain a of of only history pneumonia, month measles within a the of the preceding development pneumonia. in a number the there have been of cases of may camp During epidemic in abortive at the which measles, time, unrecognized pneumonia later. developed in all charts and tables are as of date of Figures given and admission, not of or of diagnosis development complications. Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 237 a There were deaths these cases, among pneumonia mortality of 24.4 cent. In 17 cent, of the cases per (Chart 2). per pneumonia with a of 32.5 cent. empyema developed, mortality per will seen 1 that was reached It be from Chart the first not peak a much until two weeks after the of the measles beginning epidemic, than in case the There time the of influenza was then longer epidemic. a diminution in the number of but the arrival of 6,000 cases, following a as draft second almost occurred two weeks after troops, peak, great, was the first. There a decline for ten when thereafter, steady days the admissions ceased. gradually The does follow of so as curve not that measles pneumonia closely in The first the later influenza followed epidemic. pneumonia peak the first measles ten six after the second measles peak by days ; days there was a rise in the number of cases of peak pneumonia. TABLE 1.—Bacteriology of Pneumonia During Period 1 6-15, 1917) (Dec. Examinations Made Found Organisms No. of Percentage Cases of Cases Dee. 1917 6-15, cases_ Sputum: 62 Pneumococcus I. 22 35.5 Type II Pneumococcus II. 0 Type Pneumococcus II 9 14.5 Type atypical.. Pneumococcus III. 2 3.2 Type Pneumococcus IV. 29 46.8 Type Pleural fluids: 17 eases. 13 76.0 Hemolytic streptococcus. Pneumococcus II 2 12.0 Type atypical.. viridans. 2 Streptococcus 12.0 cultures: 30 cases.. 18 Lung Hemolytic streptococcus. Postmortem Dec.15-31, 33 Pneumococcus I. Sputum: eases. Type 27.» Pneumococcus TypeII. 7 21.1) Pneumococcus III. I Type 3.0 Pneumococcus IV. Group 13 3il.ll Pneumococcus IV and Hem. Group 2 6.0 strep. Hemolytic 3.0 streptococcus. data included in this were Bacteriology.—The bactériologie period furnished the Red Cross Car with Drs. "Metschnikoff," by Laboratory and Maxwell and which was Dochez, sent to this Jobling Captain in assist to the base camp December, 1917, early hospital laboratory, manned to at that time and do the insufficiently equipped necessary work. After Dec. the base made routine 15, 1917, hospital laboratory determinations the method mice type by glucose-blood-broth (white were this not The results of work are shown in Table 1. available). The of infection with is indicated prevalence hemolytic streptococci by its incidence in the fluids and direct cultures. high pleural lung PERIOD 2 and there was a incidence of 1918, During January February, large the clinical a of lobar pneumonia, variety showing greater percentage and little from the seen in civil life. pneumonias differing very variety Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 I constituted 26.5 of cent, the whole number. Type pneumonia per March 15 and 117 cases of Between were 15, 1918, April pneumonia admitted to the 10 of these hospital, (8.5 per cent.) showing Strepto¬ in the The coccus cases to hemolyticus sputum. Type dropped 13.6 IV cent, and showed 69.2 cent. per Group per pneumococcus and cases an Between March 26 349 of acute 13, April respiratory infection were admittted. These were called "influenza" because not of lack of a for such bactériologie support diagnosis. Clinically, they resembled the condition called influenza, closely subsequently although this is diagnosis questionable. the latter half of a in 1918, number of recruits During June, large the Detention severe bronchitis. from Camp developed Sputum twenty more cases was to of the severe submitted the for examina¬ laboratory tion. In cultures made from 60 con¬ addition, were nasopharyngeal tacts with these cases and from 60 chosen at random, men, throughout the camp. : The washed three times in saline was Method.—Sputum sputum emulsified in then in dextrose-blood-broth. After and broth, planted were six to hours' human streaked incubation, eight blood-agar plates from these cultures and were studied after twelve to hours' eighteen and after hours' incubation. Pneumo¬ incubation, again forty-eight colonies were fished into dextrose-blood-broth cul¬ coccus and pure for tures submitted to the test bile and with solubility agglutination serums. Colonies wide area of and type showing hemolysis having characteristics of were considered morphologic streptococcus hemolytic streptococcus. : was cultures The swabbed for as Naso-pharyngeal naso-pharynx carrier detection. Swabs were into meriingococcus placed immediately were broth and from human blood tubes, these, agar plain plates streaked and incubated to hours. Plates were twenty-four thirty-six then studied for of colonies. such as types Organisms staphylococci and Micrococcus catarrhalis not recorded. Results are were given in 2. Table TABLE Found 2.—Organisms in Sputum and Nasopharyngeal Cultures from Camp and from Detention Number of Normal Equal Controls (June, 1918) Naso-Pharyngeal Sputum Present Contacts Organism Cases Per Cent. Cases Per Cent. Cases Per Cent ¡ I 21.1 II HI Hemolytic streptococcus. Pneumococcus I. 3 15 Type Pneumococcus IV. 15 75 Group over. 75 30 50 Hemolytic streptococcus, 14 23.2 Pneumococcus over. 75 7 14 2 undetermined, 3.3 Pneumococcus and Hem. 13 streptococcus. 3 5.0 Neither nor pneumococei streptococci... « 75.0 Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 *. ·» i8 I* S «I %*»/ %tíí %¿f ¡¿et v>? %as ì'.tì "À ti *- / ri lu a* so ?nis ¡lililí -rm-r TW iiiiii ñ. n s ti m Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 of the remainder Period after 2, the During especially Thirty-Sixth in Division left there were cases of July, only forty-three pneumonia with deaths. the two Nine of the showed forty-three hemolytic strep¬ tococcus in the a infection and two were mixed predominating sputum, of and IV pneumococcus. hemolytic streptococcus Group Of the 538 a of pneumonia patients, only forty-eight gave history antecedent infection within a an month. In the of great majority instances there was a definite of insufficient history clothing,. exposure, or followed which have been overheating, by injudicious cooling, may the factor in the onset. precipitating The total for this was 7.4 there mortality cent., period per being fatalities the 538 cases. among forty Fifty-two patients (9.7 per cent.) 37.5 and cent, of the total deaths. developed empyema per provided is that in all the lobar cases Bacteriology.—It significant pneumonia were in the and found ten of the fatal sputum, pneumococci eighteen cases reacted to serums II. and specific Hemolytic type streptococci were an in still factor and three of nine important (Table 2), purulent this was in addition to the pleurisies present pneumococcus. organism month the of there occurred four of interstitial cases During April caused the These cases bronchopneumonia by hemolytic streptococcus. occurred the time the small acute at of of infec¬ epidemic respiratory tion described. previously PERIOD 3 of The the on 17 Influenza. development epidemic September with the admission of cases of a not uncommon of began type upper tract infection, about five before the respiratory numbering daily, semblance of an was evident. On 26, epidemic September twenty-four cases were of influenza admitted. the which con¬ During epidemic tinued Nov. cases of were to 15, 1918, this infection admitted to 3,876 and the base Six hundred cases were held in the hospital. thirty-four observation of wards the Detention Camp. in Blood of the table of blood counts (Table 3) Counts.—Study that influenza shows the first five weeks, repre¬ uncomplicated during the of incidence, the number of counts senting period highest largest were below the below 10,000; was and polynuclear percentage seventy, the was over As the of the lymphocyte percentage twenty-five. severity the total counts were and the white declined, epidemic higher, poly¬ were increased. The same tran¬ nuclear percentages correspondingly sition is in the influenza apparent pneumonia following (Table 10), of is than in the uncom¬ the counts percentage high greater although cases. plicated Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 TABLE 3.—Blood Counts in Uncomplicated Influenza Cases (Based on 400 Counts Made During the First Five Days of the Disease) Sept. 1918 Oct. 1918 Nov. 1918 25-30, 1-31, 1-30, Cases Per Cent. Cases Per Cent. Cases ; Per Cent. Total counts. 49 212 139' I.o Under 8 1 5,000. 3,0 23.5 'si 70.0 Kit 05.0 5,000-10,000. 12 00 Over 24.0 32.0 105 75.5 10,000. Differential counts. 29 155 120 Polymorphonuclear neutrophils Under 50 cent. 1 3.5 3 2.0 per 50-70 cent. per 15 51.5 07 43.0 43 34.5 71-85 cent. 41.5 82 per 12 S3 53.5 05.0 Over 85 3.5 per cent. 1 2 1.5 1 0.5 Lymphocytes 10-25 cent. 31.0 07 43.5 02.5 per 00.0 25-50 cent. 85 54. 37.5 per Over 50 cent. 2.0 per was common under not a Leukopenia (counts 5,000) finding, absence of was the rule. though leukocytosis This in was a the blood with some¬ change findings synchronous what clinical The reached its in changed picture. epidemic peak numbers seven in and at the end of the second week the days, severity the of infection was as shown a less decreasing, by profound prostra¬ diminished tion, malaise, less and milder toxic general frequent more and convalescence. erythema rapid Reference to Chart 3 shows that the first of the influenza peak that of the five The second occur¬ precedes pneumonia by days. peak, three weeks coincident with later, the arrival of the first incre¬ ring ment of drafted from the second of Missouri, troops precedes peak the seven There were received the detention at pneumonia by days. the of the drafted white men course 4,108 and camp during epidemic drafted colored men. 2,360 the white 252 thousand men who men, were Among per exposed the 114 thousand infection, Not developed per pneumonia. developed a an of antecedent influenza every pneumonia patient gave history infection. 795 cases a the of of influenza Among pneumonia, history month was within the obtained in 728. preceding No deaths attributable were to influenza. The total uncomplicated deaths in the 833 cases of numbered a of pneumonia, 156, mortality 18.7 cent. men per and Thirty-six (4.3 per cent.) developed empyema furnished 11.5 of cent, the total deaths. per in the It is that of rate for interesting spite higher morbidity influenza and black the among pneumonia troops, mortality percentage them was somewhat less than of that the white (17.1 per cent.) among troops (20.8 per cent.). From Chart 2 it would at first that the appear highest mortality reached after the onset of the the virulence of was quickly epidemic, infection thereafter and the the from decreasing mortality diminishing Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 21.2 and 19.1 cent, to 12 and 9.1 for semi¬ per per cent., respectively, true is That this have been evidenced monthly periods. may partly by the fact that the admitted after the first weeks did not two patients so ill. of to be That the virulence the appear infecting organ¬ severely ism is shown the incidence and of persisted by mortality pneumonia the Missouri drafted who arrived three weeks after the among men, in of the was reached. These men arrived from peak epidemic camp 22 to 25. were October October overtaken influenza October They by and to November 23-31 October 28 4. developed pneumonia Among them there 199 cases of with deaths, developed pneumonia thirty-nine a the almost to that at (19.6 per cent.) mortality equal occurring half of the The lower total for the first height epidemic. mortality of November was due to the inclusion of scattered cases ninety-one that had been in these occurring among Among troops camp longer. cases were a 12 there eleven of cent. deaths, per only mortality were routine swabs 25, 1918, Bacteriology.—Sept. naso-pharyngeal made in all cases admitted with the of influenza. In all, diagnosis were examined cases seventy-five satisfactorily. Method : Swabs were from as described made the naso-pharynx in "Standard Method for Carriers for U. S. Meningococcus Army." human These were first streaked on and afterward blood-agar plates, in immersed The latter cultures were incubated glucose-blood-broth. about six hours were and human then streaked blood-agar plates from them. Identification: and "Standard Method by Streptococci pneumococci for S. that of other work identifica¬ U. Army," press except prevented were tion of of Plates incubated to types pneumococci. eighteen hours. Influenza bacilli when found in were twenty-four quantity in in characteristic this time. The are shown results growth present in Table 4. TABLE 4.—Bacteriology of Naso-Pharyngeal Cultures in Influenza Number Per Cent. over 75 34 45 Hemolytic streptococci (colonies per cent.). Associated organisms: Pneumococci 18 (type undetermined). . 19 Staphylococci Gram positivebacilli. 3 Unidentified undetermined over 75 26 35 Pneumococci, type (colonies per cent.). Associated organisms: Hemolytic streptococci. . 2 Nonhemolytic streptococci . 11 Staphylococci Micrococcus catarrhalis . 1 Influenza bacilli 7 9 present. Associated organisms: Hemolytic streptococci. Pneumococci undetermined). (type Micrococcus catarrhalis. . 4 Staphylococci over 75 cent.). 10 Nonhemolytic streptococci (colonies per Associated organisms: . 6 Staphylococci Micrococcus . 2 catarrhalis Friedländer bacilli. 1 Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 t. "Prie moma, "TLjpes jjo-etertcTAo^GcCA -2 3cLSadL +í or\ \Q(^0 Spu^wrn Cxo¡jvu¿q^iJx\s = of Columns Number _ICW/wT* Sputo. I % TLjpe -. °/o f^peTE ti TSE Type Croup Streptococcus (E -ß -80 J* -\ -éí ^A ^fl· ^â± -4l· --40- ^^ -3& -ê^ -e± ./' *e ^s- Si tzxi -*« ^'- 7>--. ñ -~4 '¿s | . ç*b K\cr Apr June o¿t Nov Pec Julvj &>s Sept Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 : Postmortem The Period as Bacteriology bacteriology during 3, determined cultures and incidence of in the the by lung complications of three lobar of types cases, (1) pneumonia, (2) bronchopneumonia the confluent lobular and of the inter¬ type, (3) bronchopneumonia stitial is shown in Tables 6 and 7. The the 5, type, group showing interstitial of and the of type pneumonia highest proportion complica¬ showed in 64 tions, cent, of per cultures, hemolytic streptococcus lung as our with just experience streptococcus pneumonia complicating measles had led us to expect. TABLE 5.—Bacteriology of Lobar Pneumonia as (Twenty-Four Cases) Determined by Lung Cultures Cases Not examined.. 8 alone. Pneumococcus, Type II, 1 Pneumoeoecus, Group IV, alone.. IV and Pneumococcus, Group influenza. 2 and 1 Pneumoeoecus, Group IV, influenza nonhemolytic streptococcus. Pneumococcus, undetermined, alone. 3 type undetermined and influenza. 1 Pneumococcus, type undetermined and Mierococeus catarrhalis. 1 Pneumococcus, type Influenza 25 bacillus, 4 cases; per cent. Per Cent. Complications Pleurisy, purulent. 12.5 fibrinous. 30.0 Pleurisy, Pleurisy, serofibrinous. 12.5 serous. 8.0 Pleurisy, Meningitis,purulent. 12.5 Substernal 4.0 pus pocket. Lung 4.0 abscess. . 4.0 Peritonitis, purulent brain. 4.0 Edema, duration disease Average of 9.2 days. TABLE 6.—Bacteriology of Bronchopneumonia—Confluent Lobular Type (68 Cases) Cases Not examined 17 Pneumococcus, type undetermined, alone. undetermined and influenza. 5 Pneumococcus, type undetermined and catarrhalis. 1 Pneumococcus, type Mierococeus alone. 14 Pneumococcus, Group IV, IV and influenza. 1 Pneumococcus, Group III,alone. 1 Pneumococcus, Type . 2 Pneumococcus, Type I, alone. Influenza and M. catarrhalis. 1 alone. 2 Hemolytic streptococcus, Hemolytic and IV. 1 streptococcus pneumococcus, Group alone. 11 Nonhemolytic streptococcus, and influenza.. 1 Nonhemolytic streptococcus Bacillus of alone. Friedländer, 1 3 6 cent. Hemolytic streptococcus, cases; per Influenza 8 bacillus, cases; 16 per cent. Per Cent. Complications Pleurisy, purulent. 4.5 serofibrinous. 11.0 Pleurisy, fibrinous 23.0 Pleurisy,. serous.. 4.5 Pleurisy, serofibrinous and 3.0 Pericarditis, purulent. Metastatic 3.0 abscess. disease duration of 8.5 Average days. Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 in the bacilli were found 16 cent, of Influenza per in and and 25 cent, of the lobar per pneumonias, bronchopneumonias associated with other always organisms. lobar cases the was found. In all of the pneumonia pneumococcus cases of confluent In the the lobular bronchopneumonia type, thirty- five IV per pneumococcus, (70 cent.) yielded pneumococcus Group or undetermined, nonhemolytic streptococcus. type from blood cultures were made heart's Satisfactory postmortem in as in with results shown Table 8. cases, eighty-one Table 7.—Bacteriology of Bronchopneumonia—Interstitial Type (33 Cases) Cases Not examined. 11 alone 10 Streptococcus, hemolytic,. and IV. Streptococcus, hemolytic Group 1 pneumococcus, and Streptococcus, hemolytic pneumococcus, undetermined. 2 and influenza. Streptococcus, hemolytic 1 Streptococcus, alone. 1 nonhemolytic, and influenza. 1 Streptococcus, nonhemolytic alone. 1 Pneumococcus, undetermined, undetermined and Friedliinder bacillus. 1 Pneumococcus, alone. 1 Pneumococcus, Type III, alone. 3 Pneumoeoecus, Group iV, fi4 cent. Streptococcus, hemolytic, 14 cases; per Influenza cases: 9 cent. bacillus, 2 per Per Cent. Complications Pleurisy, purulent.-. 40 serofibrinous 18 .. Pleurisy, fibrinous. 28 Pleurisy, serofibrinous and 9 Pericarditis, purulent. . 9 Peritonitis, purulent Substernal 9 pus pocket. Metastatic abscess. 3 abscess. 6 Lung duration of disease 14.5 Average days. of Cultures from TABLE 8.—Bacteriology Heart's Blood (Postmortem) Total cultures. 81 No. 19 growth undetermined. 19 Pneumococcus, type GroupIV. Pneumococcus, Type 1 Pneumococcus, II... 2 Type. Pneumococcus, III. Pneumococcus, Type hemolytic. 11 Streptococcus, Streptococcus, nonhemolytic. cases of lobar have cases, Diagnosis.—Certain especially pneumonia, in the offered no In those difficulty diagnosis. secondary pneumonias, in measles in and those influenza 1917, especially following following was so it the rule rather than the for the to be 1918, exception signs as to offer the in not to as irregular greatest difficulty diagnosis, only evidence of but as to the clinical the consolidation, especially variety. these have all shown The from cases practically sputums streptococcus, or a mixed infection. IV, pneumococcus Group Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 How we have failed in the differentiation of the clinical badly types of under the conditions be seen here, pneumonia existing may by reference to Chart 8. In and October the November, measles 1917, during epidemic, there were 626 cases came of of which to pneumonia, fifty-five these lobar was necropsy. cases, Among fifty-five pneumonia diag¬ in as in nosed fourteen, two per correctly bronchopneumonia (14 cent.). was in as cases, lobar Bronchopneumonia diagnosed twenty correctly in cases per cent.). pneumonia twenty (50 Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 In influenza and 1918, the October, epidemic, September during to there were 714 cases of of which 122 came necropsy. pneumonia, these Of 122 were lobar cases, eighteen diagnosed correctly pneu¬ fifteen were called monia, bronchopneumonia (45 per cent.). wrongly nine- were as cases ; properly diagnosed bronchopneumonia Eighty-one cases were called lobar There teen pneumonia (19 cent.). wrongly per for these were certain circumstances wrong diagnoses. extenuating the was at table differentiation Even the frequently postmortem The fact remains on clinical differentia¬ that statistics based puzzling. between lobar seen this tion and at bronchopneumonia hospital during existence not the first months of its are reliable. For this sixteen Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 reason we have included the differentiation in the tables and not Chart will serve as a charts, in which with 7, except comparison figures sources. furnished from other in the Onset.—As this was observed measles pneumonias following in was a difference in and those influenza, there the following great two In 1917 an it took for acute infec¬ epidemics. apparently longer tion of the tract to into a A upper respiratory develop pneumonia. of an infection several before acute weeks the history existing pneu¬ was monia often obtained. In the pneu¬ developed post-influenzal the of consolidation later than five monias, signs rarely appeared days after the initial of the the duration of the febrile symptoms influenza; two most of influenza been to five often three. period having days, were The infections both of the des¬ following epidemics usually some the involvement In cases of the and cending type. lungs pleura almost it doubtful whether the con¬ appeared simultaneously, leaving solidation or came In the first. the empyema 1917, especially, pleural involvement was often the initial and feature the outstanding ; pain the was the face the features intense, extreme, flushed, prostration fluid formed before of con¬ drawn and (usually streptococcal) signs were cases solidation manifest. In the of and chill did majority pain not in the onset. The increased and figure temperature, high pulse increased were indications for careful and rate respiratory frequently examinations. repeated physical 1 2 and cases were seen in which the During periods occasionally of ushered in the infection. the signs meningitis Usually, meningeal for about then the first of hours; signs persisted twenty-four signs consolidation would fluids were appear. Spinal negative. cases in the of these difficult Signs.—The physical signs majority were and frank. Dulness, extremely irregular rarely suppressed often moist at the of breath râles, sounds, crackling especially height or even a in the of the breath and voice inspiration, change quality the the sounds—one or more of but were bases of these, all, rarely In the absence of evidence—such as the subse¬ diagnosis. supporting course of the counts and disease, quent leukocyte roentgenograms of an these cases would not have been It was not many diagnosed. to have the frank follow several infrequent experience signs days in after the decline of and the temperature improvement general condition. cases in Lobes Involved. Of which the first involvement 1,533 affected one the lower lobe was first noted lobe, involved in right only 711 in 679 in the left lower lobe the lobe 54 cases, cases, upper right the in in left lobe 48 and the middle lobe 41 cases, upper cases, right In a number of the cases of associated with cases. large pneumonia Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 the influenza the initial involvement was simultaneous in epidemic, lobes. It is of in four both lower anatomic interest to note that an on additional lobe was observed twice the left and twice necropsies on the side. right 2 the Blood Counts.—In Periods 1 and blood counts were such as encountered in are the first five pneumonia. During ordinarily days of the disease about 85 cent, of the total number of white counts per the made over and in the same of cases was 10,000, proportion poly- nuclear was 70 or over (Table 9). percentage TABLE 9.—Blood Counts in Pneumonia Period 1 Period 2 Period Influenza 2—Following Sept. 25- Jan. 1- Dcc. ! 1-31 31, Sept. 27, Sept. 28-30, Oct. 1-31, Nov. Cases Per Cases Per Casesi Per Cases Per Cases Per Cent. Cent. Cent. Cent. Cent. Total Counts: first five During days- Under 2 10 5,000. 4 10 6 12 5.000-10,000. 12 3S 79 (¡0 7 Over 13 S4 16 51 41 31 10,000. After five days— 19 1 43 24 30 5,000-10,000. Over 18 SI ß 57 70 100 10,000. Differential Counts: Polymorphonuclears- 50-70 cent. 10 2 5 25 43 2 per (14 70-85 cent. 21 53 17 75 54 19 per Over 85 cent. 25 L9 42 3 2 per .. When are the for these two with those figures periods compared for Period it will be noted are 3, that reversed they very nearly 60 cent, of these counts under while in 35 cent, per 10,000, being per the was below polynuclear percentage seventy. It is not unreasonable infer that the failure of the individual to to react to his with a at this time is evidence of pneumonia leukocytosis a diminished resistance influenza. In the this produced by preceding in connection it is to note that of made counts interesting thirty-one cases in no was which antecedent of influenza history present during Period 3, were over and 10,000 15,000) twenty-seven (average only four were below Also that the duration of illness in 10,000. average the fatal cases first two was while in twenty-one during periods days, the last was it eleven period days. Blood Cultures.—Oí 254 blood cultures taken satisfactory during or in life, 13.8 cent, were Of the 219 per cases thirty-five, positive. which sterile blood cultures or 11 were obtained, twenty-four, per cent., of the whereas of the cases with died, blood patients thirty-five positive Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 cultures or fourteen 40 died. This is in accord with per cent., patients, that the view a blood culture life makes the positive during prognosis grave. Examination Chart 6 shows Bacteriological of Sputum. type the cases determinations for 1918. Of the 1,371 of year pneumonia in in the or 79.5 was 1918, 1,090, occurring sputum cent., typed. per From Dec. III serum was obtain¬ 28, to 20, 1918, not 1917, Jan. Type IV III able for this include some ; therefore, may Group period Type cases. the four winter months—December, During January, February and March—the of incidence of was 23.8. The percentage Type was incidence the of weather 5.9 cent. With period per during good II the winter months showed an incidence of 11.1 cent.— Type per the summer months 3.1 In the decreased inci¬ cent. contrast to per of dence these fixed IV 61.9 shows Group pneumococcus per types, in winter and summer months. cent, the months 69.2 cent, in the per curve The includes both and streptococcus hemolytic non-hemolytic and resembles the IV in its curve variations. streptococci, Group TABLE 10.—Pneumonia : Cases and Mortality on the Basis cf 1,090 Sputum Type Determinations Cases Deaths Mortality, Cent. per Pneumococcus I. 7 4.9 Type Pneumococcus II. 14 20.0 Type Pneumococcus III. 45 13.3 Type Pneumococcus IV. 722 75 10.4 Group Pneumococcus TV 25 6 24.0 Group and Hemolytic strep. 5 5 100.0 Nonhemolytic streptococcus. . 11 13.3 Hemolytic streptococcus. the The in various of as mortality infecting types organisms, determined is shown in Tables 10 and 11. examinations, by sputum note the in It is to variations for the same in interesting mortality type different All with the of showed periods. types, exception III, Type a Period much 3 the influenza higher mortality during (accompanying than had shown the first nine months of the epidemic) they during year. TABLE 11.—Periods 2 and 3. Mortality of Various Types of Organisms Compared Mortality Mortality Percentage, Percentage, Oct.-Dec. Jan.-Scpt. Pneumococcus I. Type 7.4 Pneumococcus II. Type 37.5 III. Pneumococcus Type 12.5 Pneumococcus GroupIV. 12.0 and Streptococcus—hemolytic nonhemolytic 23.0 at this has shown that to limit the Experience hospital investiga¬ to tion of a determination of the of pneumococcus sputum type present, Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 a as does not reliable to the nature of the always give guide existing infection. We need call attention to a of our only comparison sputum in fluids and with the found determination, type bacteriology pleural 1 to It at Period illustrate this necropsy, during (Table 1) point. seems to to determine the attempt necessary predominating organisms. been to this from a differential count of Our has estimate practice on human streaked colonies from either first culture blood-agar plate in the or from the of mouse. glucose-blood-broth peritoneal cavity in the the with the other Comparing findings sputum bactériologie in same such as from the examination of blood the case, findings should furnish cultures, fluids, cultures, necropsy, etc., pleural lung the best evidence as to their value in Such a ordinary hospital practice. is made in Table 12. The of comparison correspondence percentage is conditions into consideration the under which the work high, taking and was indicate that this should remain one of our done, procedure the routine methods for of diagnostic study pneumonia. TABLE 12.—Comparison of Sputum with Other Bacteriologic Findings With Other Bac¬ Corre¬ Per Dif¬ Per Sputum Cent. ferent teriologic sponding Cent. Findings Pneumococcus I. 7 5 71 2!) Type tí Pneumococcus II. 12 50 50 Type 1 S4 Pneumococcus III. ß 1« Type Pneumococcus IV. 74 54 34 16 Group 17 13 7fi 4 24 Streptococcus, hemolytic. 4 75 1 Streptococcus, nonhemolytic. con¬ Course.—The toward a fatal termination varied progression as in those cases in the fall of contrasted 1917, siderably occurring in the fall of 1918. In the former an extreme with those period anxious with all the hoarse, facies, accessory cyanosis, barking cough, of a fearful of what muscles in use, picture respiration presented was seemed the horror of death. In there little 1918, comparatively in the infections death was of this. Even streptococcus preceded by a much more This true in the of the was case quiet period. especially were none in in remained camp 1917). negroes (there They usually with shallow and met death respirations, quietly. quiet in 4 the deaths the Chart shows two occurring epidemic periods with reference to the duration of the illness. the Accompanying it is an number for measles the first always increasing week, epidemic the and after second week. the influenza the second week During in the number in the first week is than that epidemic dying greater and the least number survive more than the second week, days. Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 TREATMENT OF PNEUMONIA in serum been used all I Serum has Type Therapy.—The specific of those which had defervesced at the time cases, except practically determination. type The time between the to the and the sending sputum laboratory the serum twelve the of was to hours, during giving eight except of all when the stress of work the prevented desensitizing epidemic, as was as soon the made. pneumonia patients diagnosis There were 142 infections. One hundred and 1918, during Type were treated with died mor¬ serum; seven twenty-five patients seven while of 5.6 cent. Four of these deaths, per tality (Table 13). were to caused charged pneumonia, really by empyema, twenty-nine, and fifteen after the twenty-eight, twenty-four days, respectively, these of the the mor¬ deaths, pneumonia. Eliminating development cases 2.4 of the treated would be cent. per tality TABLE 13.—Complications Cases Per Cent. Total Recognized Recognized Cases at Only at Only Necropsy Necropsy 28 11 Empyema. with effusion. 101 Pleurisy Otitis media—suppurative (22 bilateral). media—catarrhal 40 Otitis (13 bilateral)_ Mastoiditis (2 bilateral). 24 58 Pericarditis. 17 18 abscess. Metastatie Emphysema, subcutaneous, generalized.. 10 100 mediastinal tissues 10 Emphysema, only.... abscess. 9 Lung 2 17 Meningitis. 8 «7 Peritonitis. 7 100 Substernal pockets. pus Thrombophlebitis. chronic Nephritis, parenchymatous. toxic. 18 acute Nephritis, Sinusitis. Myocarditis. Toxic psychosis.— I untreated. None of these Seventeen infections were Type were most those The untreated for the died. patients part patients or in of their sent because of the mildness infection, who,' delay being of infection could into the had their crisis before the the type hospital, determined. A few of these were sensitive to horse serum, be patients treated because were not sick. but were not very they and results have followed the administration of No serious serum, our a for its use. The we feel that is experience strong argument more are the results obtained. This is earlier it is the used, striking of defervescence shown in Chart which the relation of the 5, gives day on which treatment to the serum was begun. day Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 as soon as received in doses Digitalis.—All patients digitalis large the was made. In Period when a standardized tincture 3, diagnosis was was administered in obtained, it therapeutic dosage. General Measures.—Treatment other than that referred to already was symptomatic. Gross : The first cases to Pathology.—Period coming necropsy in showed the well lesions of acute November, known, 1917, typical lobar Of the first cases two showed effu¬ pneumonia. eight pleural sions one serofibrinous and the other purulent. TABLE 14.—Relation of Pleural Exúdate and Sputum in Sixty-Eight Cases of Empyema ! Percentage Cases Deaths of Mor¬ tality 1. Pneumococcus in both and sputum pleural fluid. 32 19 2. in both and Hemolytic streptococcus sputum pleural exúdate. 33 3. and in both Pneumococcus hemolytic streptococcus and exúdate. pleural 30 10 33 sputum in 4. Sterile empyemas, pneumoeoecus 3 0 0 sputum. Total. more As measles became and as both the incidence and prevalent, of the More lobes were mortality pneumonia rose, picture changed. involved. Instead of firm and the affected feeling airless, uniformly or tissue felt and distinct could be nodular, "shotty," crepitation elicited between the firm nodules. Fibrinous over the deposits pleural surface constant were more and more extensive. On the section, cut surface of mottled a dark, lung presented usually appearance, bluish-red with small elevated red background, many slightly grayish each of the a or near areas, bronchiole, at its presenting opening In cases center. these areas were confluent. The interlobular many were visible, the lobe into number of septums distinctly dividing areas. Abscess formation, small irregularly shaped especially multiple was abscesses, found. occasionally Effusions into the became and pleural cavity increasingly frequent, were visceral Adhesions between the and usually purulent. parietal often the into two or more occurred, pleura dividing pleural cavity distinct the most site of such compartments. Perhaps, frequent costal adhesion was between the anterior of the and the edge lung or the inner surface of the sternum sac. Here margin, pericardial were at times divided transverse bands formed, elongated pockets by into which contained thick two, and masses of fibrin. greenish pus Adhesions lobes with formation of between the interlobular abscesses were also found. Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 in cases. In some The was involved instances pericardium many surface a fibrin the external showed of thickness only deposit varying with and adhesion to ribs and left In sternum, organization, lung. other inner surface was with a fibrin the dull, covered instances, rough and the contained a amount of serofibrinous sac or deposit, large in which were found. fluid, purulent hemolytic streptococci TABLE IS.—Procedure in Empyema Method Period Period 2 Period Total Mortal¬ of Aspira¬ 1 3 tion Cases Treatment ity per Cases Deaths Cases Deaths Cases Deaths Cent. No. 21 20 23 3 7 71 Aspiration alone 3 2 75 20 20 27 121 10 2 8 20 10 3 4 0 io 10 2 1 1 1 4 0 Costateetomy 1 0 preceded by 2 0 aspiration 0 1 0 10 1 11 5S 2 3 Thoraeotomy 3 1 75 preceded by aspiration 5 100 Costateetomy Thoraeotomy Aspiration Mortal¬ Mortal- Mortal- Mori al- Cases Deaths Cases Deaths Cases Deaths Cases ity per ityper ityper ityper Cent. Cent. Cent. Cent. Period 1* Oct. 1- 67 0 Dec. 31, 44 Period Jan. 1- 0 10 21.3 Sept. 43 27, Period 27- Sept. 25.(1 33 24 Dec. 31, 100 38 221 Total 23 had no before death. Two cases included in totals for aspiration only aspiration (2 deaths) cases was that The in these Microscopic. microscopic picture as interstitial The illustrations described MacCallum1 pneumonia. by MacCallum, W. G.: Pneumonia at a Base 1. Cole R., and Hospital, A. M. A. 70:1147, J. Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 show some of the constant peribronchial consolidation, findings of interstitial and extensive involvement tissue, fibrino-purulent pleurisy. a confluent lobular 1.—Section of affected with bronchopneumonia Fig. lung influenza. exúdate. following Early PERIOD 2 was found in nine¬ Of lobar pneumonia twenty-five postmortems, was teen cases of the interstitial found in type, ; bronchopneumonia, six cases. The incidence of was per purulent pleurisy high (50 cent.). six This the fact that five of the be may by bronchopneu¬ explained cases this were monia showed and hemolytic complication, streptococci as cases found in one-third of the complicating organisms following infection. pneumococcus Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 3 PERIOD were Gross distinct of cases found: (1) Pathology.—Three types lobar of interstitial the pneumonia; (2) bronchopneumonia type, lesions of which have been and described, just (3) bronchopneumonia a or of lobular confluent type. with a confluent lobular 2.—Section of affected bronchopneumonia Fig. lung following influenza. Later exúdate. the latter were more or In the all firm, cases, lungs large, moderately less nodular. areas careful could Frequently, by palpation, crepitating even a which was consolidated. be in lobe felt, apparently completely cases The was smooth and many pleural covering usually transparent, scattered small of Fine fibrin¬ areas showing subpleural hemorrhage. found in some cases in the course of the ous were deposits very early Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 In cases those which showed of the medias- pneumonia. emphysema was an beneath tinal tissues there the just usually emphysema pleura which extended the interlobular mainly along septa. Section of the was followed the of a lung by outpouring large of fluid. The cut surface was bluish amount dark, dark, red, bloody in a mottled with which varied color from brownish- areas, lighter deep 3.—Section of lesion in a case of interstitial Fig. lung showing pleural caused the pneumonia by hemolytic streptococcus. a or red to and varied in size from grayish-red, light grayish-yellow, one or two centimeters in diameter It was common to find up. very areas In of different color and in the same lobe. the lower consistency lobes these and areas were most confluent, so that at times it largest was difficult to whether or not the consolidation was say homogeneous. In such the lobes showed distinct cases, however, upper always patchy consolidation. Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 The is shown in the illustrations. microscopic picture accompanying of Its characteristic features the intense edema and were congestion of in all interstitial the marked exúdate tissues, predominance bloody the alveoli in most and the distribution of the cases, lesion, irregular nor areas different not diffuse, but at showing strictly peribronchial in the same section. of stages development 4.—Section of from a case of interstitial Fig. lung pneumonia caused the by hemolytic streptococcus. The raised not to here be whether it is desirable might question the used as to cover a condition so term drop pneumonia pathologic variable in its manifestations and Careful of etiology. reading reports from to the firm belief various leads that the clinical hospitals diagnosis in cases cannot a of be made to conform with the large percentage lesion lobar and inter- pneumonia, pathologic bronchopneumonia Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 stitial Medical have used the terms lobar men, pneumonia. generally, rather the and loosely, diagnosis being bronchopneumonia usually on a one based the of consolidation of or the whole of presence part or more lobes. In such of the made workers as Cole and his asso¬ reports spite by at Rockefeller of ciates the the of Institute, knowledge bacteriology has been rather With the with vague. pneumonia unhappy experience in in in both civil life and the the fall of pneumonia, army, especially men come in numbers of medical have contact with the 1918, large in disease in a form and of manifestations amount exceeding variety in nomenclature their If in the anything previous experience. changes can so as indicate a difference be made to in the treatment prognosis, and the to be looked much will be for, complications accomplished. in the Another would be attained varieties advantage emphasizing of The inclusion of acute the infecting organisms. pneumonia among is infectious diseases recent. It is that the comparatively probable cases in a of such medical ward is and day treating general past, yet we have entered into the of the various scarcely practice isolating types of It is as undesirable to a of "acute case pneumonia. just expose lobar an as to to "acute pneumonia," streptococcus pneumonitis" medical case to either of the above. Isolation of expose any general the various of be will types pneumonia probably practiced generally in In all well conducted such with labora¬ hospitals. places adequate be facilities there will no reason for otherwise. tory doing In it is that the must private practice average probable physician to or look the state for differentia¬ sputum municipal laboratory type as now he does for examination for Klebs-Loeffler bacilli. tion, health some will Unquestionably, departments provide specific serum, and for its administration. Such when type provide differentiations, as a of serve the will to accentuate the incorporated part diagnosis, of cross infections all the importance avoiding by using present methods of and their further prophylaxis stimulating development. it be well to do as has Would therefore, been done with "rheu¬ not, reserve matism"— the "acute lobar for those diagnosis pneumonia" are cases of which well defined epidemic pneumonia fairly clinically, I or to and due either to with its pneumococcus, serum, Type specific fixed II the of and and I, III, the term types pneumococci, apply causative "acute the whenever pneumonitis," giving organism possible, various conditions now called to the other lobar, lobular interstitial, or or terminal etc. ?2 bronchopneumonia, septic pneumonia, pneumonia on and Fox in and 2. Hamburger reporting pneumococcus streptococcus used the term infections at Camp Zachary Taylor "pneumonitis." Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 COMPLICATIONS : cases Of of 249 the 2,344 Empyema pneumonia, developed an incidence of 10.6 cent. This incidence was a empyema, per steadily for the three 9.5 4.3 one 16.5, and decreasing periods, being cent., per Period 1 41.5 furnished cent, of the total per pneu¬ respectively. and 64.6 cent, of the total cases of whereas monias, per empyema, Period furnished 35.5 of 3 cent, the total and per pneumonias, only 14.4 of the total cent, per empyemas. DIAGNOSIS difficult in certain The of in the chest is very cases, diagnosis pus on much less so in others. This the amount character, depends largely location of the and whether or it occurs or late and effusion, not early of often demands all in the course the Its recognition pneumonia. the can on aids to that be summoned. The rests diagnosis diagnosis one or more of the in condition of following: (a) Change patient; and some¬ (b) physical (c) roentgenography fluoroscopy (d) signs; a in and increase not the count times, often, though change leukocyte in the number of cells be may polynuclear helpful. Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 in the Condition of Patient: course of the ( ) Change During comes there a between five and ten time, pneumonia usually days, the when in the absence of extension of the temperature, process should with the and either rates, fall, together pulse respiratory by or the remissions crisis If this fails to and if occur, lysis. especially should be aroused. In some cases the increase, suspicion temperature falls after a number of an afternoon rise of to normal; varying days We have had cases in which was temperature begins. pus present the where the fell to normal after temperature primary pneumonia, rise 99 F. after had been and did not above until the evacu¬ again pus Where the rise in ated. Chills have been rare. tem¬ and sweating or when convalescence is must be perature slow, persists, pus always cases been the first have where Many diagnosed suspected. ultimately was raised the slow convalescence and the suspicion by presence very or of were considered most pus probable. tuberculosis The have been physical (b) Physical Signs: signs notably irregu¬ no one considers the of conditions and wonder when lar, multiplicity The fluid from sero¬ vary thin, existing. may dirty (dishwater) in as in fibrinous the exúdate, color, slightly greenish early hemolytic to a dense in some streptococcus fluids, creamy pus pneumococcic In infections. between all are gradations. In a breath our with in and voice dulness, experience change a more or sometimes diminution, sounds, frequently bronchophony the best indications for a are requesting roentgen-ray egophony, be even this limited to a examination, though may fluoroscopy. With evidence from these and sometimes aids, without, supporting no a one or times. hesitation has been felt in needle many inserting In cases has been the occa¬ hundred needled, the many mishap only was no serious sional of air into the which of entrance pleural cavity, A we is have that the precaution needle, import. particular practiced the the chest once withdrawn inner surface of is to inserted, always a area. wall before the direction in order to different changing explore The This is done to avoid the tissue. of insertion point tearing lung over area of maximum since the rule rather than the is the signs, In a cases is for the to be few marked sensi¬ pus pocketed. exception on has tiveness to locate the pus. percussion helped are but a rule is to insert the needle Often signs misleading, good if is a reasonable basis for to be Fluid there believing pus present. over was has been obtained in areas which there dulness rather than a fremitus little with friction rub and vocal and flatness, present, in voice or breath sounds. On the other areas over hand, change was fremitus which there flatness, absence of vocal and markedly Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 In diminished failed to show fluid. breath sounds, have frequently latter is that a the case the there was dense fibrinous probability serous a a with little element. after Sometimes, pleurisy, dry tap, the site small of has at of the drop pus appeared puncture following the withdrawal of the needle. use Examination: The of the has ray (c) Roentgen-Ray roentgen been of the assistance in greatest diagnosis. the the the The relation of found in fluid to organism pleural pre¬ dominant Table of the is shown in 14. The organism sputum mortality of 19 cent, in as with per pneumococcus infections, compared per in and is in cent, mixed accord with the situa¬ infections, streptococcus tion as from other reported many hospitals. Table'15 the in for all Of the empyema gives procedure periods. cases 221 to or 67.9 occurred death, 150, cent., diagnosed previous per in Period 1. Of these 150 121 were with a patients, operated on, of 34 Of the rfot cent. per twenty-nine on, mortality patients operated a cent. of 89 of the died, per twenty-six mortality Twenty-one twenty- nine died after the These men were diagnostic puncture. practically moribund time of sick withstand at the too to the shock of diagnosis, The of choice has varied with the several chiefs operation. operation section. 1 it was of the In Period surgical costateetomy, thoracotomy the done in bad risks. Of the fifteen on whom a thora¬ being patients was a 73 cent. done, eleven of died, cotomy mortality per Choice of the Time of As in most the Operation: hospitals, early was to as soon as the established. was The practice operate diagnosis was a result immediate In the very high operative mortality. strepto¬ where a coccus infections, especially purulent pleuritis developed early, meant a on the prompt operation usually collapsed lung side, operated was and the with little func¬ very consolidated, possibly opposite lung tissue These at the tioning lung remaining. operations, performed meant of the either from shock or toxemia, death, height asphyxiation. With this in was view, done second experience aspiration every day for certain and the intervals increased thereafter. period gradually transition The from the thin fluids in the commonly strepto¬ present coccus infections to a thick occurs in a variable time. pus, Frequently this has occurred in hours. Ten to twelve is the forty-eight most days interval. the it is frequent Generally speaking, longer away possible to from the acute the favorable get more the end result. infection, If, the condition these should by repeated aspirations, general improves, In be continued. the case the will become average pus so ultimately thick as to render further In a certain number aspiration impossible. is still of even cases, the condition though aspiration possible, general of the becomes the rate the patient worse, increases, pulse temperature Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 becomes with an in the Chills irregular, increasing height evening. and are rare in cases. these sweating In even with the condition of many the cases, general patient fairly the time will come when with satisfactory, operation, irrigation, a more In than continuous Period promises recovery rapid aspiration. were admitted with thick formed, too many patients pus already thick to be withdrawn a were needle. These through large patients too sick to sent the to for a justify being roentgen-ray department picture. Medical aside from attention careful to Care.—Postoperative care, and is a one. to medical Attention drainage irrigation, nutrition, largely the of cardiac stimulation, and careful examinations question frequent of the chest for of accumulation of pus, effusions, signs pericardial are most Later matter etc., the it is a of "condition¬ important points. and hikes, ing," breathing carefully graduated setting exercises, up etc. games, In our this attention can best be these opinion, given by retaining on the Medical Section or more with one patients qualified surgeons to this section for the assigned necessary operative work, irrigations and It is essential that a man filled with enthusiasm for his dressings. and of the work, technic, should receive possessed surgical necessary an such assignment. Metastatic Abscesses. Metastatic or abscess, single multiple, in seventeen cases occurred of Of these seventeen cases pneumonia. four came Five to three not accompanied empyema. necropsy, being death. before One of these cases was a small diagnosed undiagnosed in abscess the first intercostal muscle a second was a case ; perirenal abscess. The most cases were of this five cases in interesting group which a tumor was noted above the not painless just symphysis pubis, to of red and not tender The first these No. cases pressure. (Reg. 2422) was not until rounded there a tumefaction recognized appeared exactly in the about inches midline, two above the extending symphysis pubis. The was a but tumor to be distended on catheteriza- bladder, thought tion small amount of urine was One very obtained. hundred cubic centimeters of salt solution was introduced into the bladder, and the same amount was withdrawn. The tumor was still The present. pos¬ of diverticulum of the bladder was considered. was There sibility no increase in no and muscular the next temperature, rigidity. During six there was a but increase in the the size of days slight, constant, the normal meanwhile a of urine. On tumor, amount patient voiding the sixth fluctuation was obtained. An incision was made and about day 150 c.c. was of thick found between the muscle pus rectus and right Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 its Culture sheath. showed a undeter¬ posterior pneumococcus—type mined. cases same The other the except presented practically picture, was that in three the tumor slightly asymmetrical. Subcutaneous subcutaneous Emphysema.—Generalized emphysema, as a of occurred in seven white complication pneumonia, eight cases, men and one man. colored Three of these recovered. patients The onset of the to be associated emphysema appeared definitely an with severe of in one case. Hoarse¬ paroxysm unusually coughing increased ness and were the refer¬ dyspnea only symptoms apparently able to this complication. tissues in The of the but also the neck, posteriorly especially, supra- clavicular were involved in all the cases the region, eight ; interscapular was involved in four the axillae and in three region ; pectoral region ; the face in flanks in one. three; the and thighs The three who recovered had a convalescence. patients prolonged Each one a had hoarseness. examination showed persistent Laryngeal an acute which One has only laryngitis, disappeared slowly. patient since been found to have tuberculosis. pulmonary Anaerobic antemortem blood cultures sterile in in were two cases; third the case showed undetermined. they pneumococcus—type Of the cases all showed of the mediastinal postmortem emphysema connective in addition to the evident subcutaneous tissue, emphysema noted life. Petechial were in evident during subpleural hemorrhages cases. two Free air beneath the visceral the pleura, especially along was seen cases. interlobular and in two One case fissures, spaces lung showed confluent of consolidation patches having undergone softening and abscess cavities. small areas of hemor¬ produced Microscopically, were in cases as cases these in other of the rhage frequent pneumonia same period. In addition there were cases ten of of mediastinal tissue emphysema at diagnosed only necropsy. of the mediastinal tissue marked Bactériologie study showing in with the was cases results on emphysema attempted eight following culture No 3 growth. Pneumococcus IV. Group . 1 Streptococcus, nonhemolytic Streptococcus, hemolytic. in In each case the was also found the blood present organism stream. one In case with most marked subcutaneous before emphysema an emulsion of tissue death, was emphysematous injected intravenously Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 a into rabbit. The rabbit was killed in five minutes and in the placed All incubator for hours. as well as heart's blood, eighteen organs, a IV which was also isolated from the gave pneumococcus Group heart's blood of the patient. SUMMARY of the cases of here fol¬ large percentage pneumonia presented lowed an of measles and an of influenza. epidemic epidemic Following the of of the epidemic measles, predominance hemolytic streptococcus as the determined the and the infecting organism high mortality high incidence of complications, especially empyema. the of influenza the incidence of Following epidemic hemolytic when lesions was but the did not less, streptococcus present produced cases from those in of the In addition to vary year present previous. was a cases the infections there of of mixed streptococcus large group with IV, bacteriology pneumococcus, especially Group predominating. the of the to 1918, During part period, January September, greater the character of the and were not infection, mortality complications different from those the essentially occurring ordinarily. Throughout were first of this of fixed I and II part period, pneumococci Types as found in the same of cases when these approximately proportion were first described. From that time on declined types they steadily until less than five cent, of the cases showed their per presence. Definite evidence of the of a the B. as deter¬ influenzae presence factor in the of the fall of 1918 mining pneumonias following epidemic was not obtained at this The whatever its hospital. epidemic, etiology, caused of resistance which favored invasion lowering by organisms identical with those which observation had during nonepidemic periods be in the shown to tract of individuals not respiratory present upper from suffering pneumonia. Postmortem studies show that the is pneumococcus constantly pres¬ ent in lobar while the with a pneumonia, hemolytic streptococcus, in of other and the is found broncho¬ variety organisms, pneumococcus, pneumonia. of examinations with more accurate bactéri¬ Comparison sputum data from the has shown a same in ologie cases, correspondence large If the examination is made with a view to deter¬ percentage. sputum the its value is mining predominating organism present, greatly one enhanced and in this form it is of the valuable diagnostic pro¬ in cedures pneumonia. Clinical differentiation between lobar and to bronchopneumonia accord with has been For this reason postmortem findings impossible. it is that the term acute followed a state¬ suggested pneumonitis, by ment of the in the be used to predominating organism sputum, desig- Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015 cases are not in but nate those of which lobar pneumonia frankly type, one caused of the fixed of by types pneumococcus. was The incidence of the fol¬ among empyema highest pneumonias measles. For the entire cases with empyema period, complicated lowing 10.6 of the total and furnished 25.6 constituted cent, per pneumonias, total deaths. cent, of the per pneumonia the The of the exúdate caused by appearance pleural Streptococcus was fol¬ characteristic. of such fluids, hemolyticus Repeated aspiration has lowed after the acute has subsided, by operation pneumonitis given more results at this the satisfactory hospital. occurrence of in The was encapsulated very common, especially pus infections. These the were frequently multiple streptococcus pockets an and offered difficulties from great operative standpoint. Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 06/07/2015

Journal

Archives of Internal MedicineUnpaywall

Published: Jul 1, 1919

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