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EXTRACTS FROM REPORTS RELATIVE TO INFLUENZA, PNEUMONIA,
AND RESPIRATORY DISEASES
This disease has always been present in camp during the year, cases having been reported each week except those ending July 25, October 18, and October 25. During the three months of January, February, and March a rather large number of cases developed, and the influenza epidemic during September and October accounted for a big jump in the reports.
Pneumonia has been very largely the predominant variety, very few cases of lobar pneumonia developing. Primary cases have also been few in number-a big proportion of the total number of cases having complicated influenza or measles. No distinction has been made until recently between the various diseases, which have been complicated by pneumonia, and comparative statistics can not be offered. In the cases occurring last spring, the hemolytic streptococcus appeared commonly and was associated with all four types of pneumococcus; the latter being greatly in the
minority. The cases occurring during the autumn showed few hemolytic streptococci, but types II and IV pneumococcus and the Pfeiffer's bacillus were found in large numbers.
During the portion of the winter of 1917-18 embodied in this report, epidemic pneumonia prevailed to a marked degree. It attained a rate in this camp and in four others in the South heretofore never observed among civilian communities and attracted profound attention of the medical profession in general and the Surgeon General's Office in particular. During January the pneumonia wave reached its apex and thereafter very slowly declined until the month of August, when very few cases were reported. The last week of August brought 1,500 colored general-service men from Georgia. Within two weeks after their arrival and assembling under unaccustomed domestic relations, pneumonia made its appearance among them. This epidemic ran from about August 15 to about the 1st of October. Between the last week in October and the middle of December occurred another epidemic coincidentally with the epidemic of influenza.
The colored men furnished by far the greater ratio of cases in the total for the period covered by the epidemic. The ratio of colored to white soldiers in camp was approximately 1 to 5. The total pneumonia cases for the epidemic period, October and November, was 1,217, of which 666 were colored and 551 were white. In the event that there had been as many colored troops in camp as white, at the prevailing ratio there would have been 3,330 colored pneumonia cases, thus showing in this mixed epidemic a continuance of the ratio of colored to white pneumonia as demonstrated during the epidemic of 1917-18, all of which tends to establish the fact of susceptibility of the colored man to pneumonia, regardless of type.
The number of patients received and treated during the past year on the medical service is about 12,000. On account of the two large epidemics of pneumonia, one during August and September and the other during October, November, and December, a very large percentage of the cases managed and treated have consisted of pneumonia. A very large percentage of autopsies (about 90 per cent of deaths) secured by combined efforts of the pathological and medical sides have been a tremendous help and stimulus in the diagnostic work. The low mortality death rate in pneumonia, namely, 13.7 per cent for all types for the year, can in part be explained upon the grounds of the early recognition and the skillful management of the complications, especially the empyemas, as well as the conservative method of treatment employed. Two distinct epidemics of pneumonia occurred in Camp Wheeler during the past year. The first began about the 15th of August and continued to the 1st of October. The second came on coincidentally with an epidemic of influenza, beginning about November 9 and ending about December 15. From August 27 to September 13, during the height of the epidemic of pneumonia, the number of patients with pneumonia in the hospital averaged more than 100 daily, reaching the maximum on September 1, when 135 patients in all stages of disease, including convalescents, were in the hospital. However, the number of patients treated in the hospital during this epidemic was small as compared with the number cared for during the epidemic of pneumonia associated with influenza. On the 13th of October there were approximately 100 patients with pneumonia, both lobar and broncho, in all stages of the disease, including convalescents. By November 6 this number had increased, to 336. During the height of the epidemic, from November 6 to November 23, more than 300 patients in all stages of disease, including convalescents, were cared for daily in the hospital. From November 23 to present date the number has gradually declined, but even now (Dec. 31, 1918), 150 patients are still in hospital with pneumonia, most of them, however, in the convalescent stages. The total number of cases cared for during the year was 2,001. Due to the studies in the laboratory, plus those supplemented by the special pneumonia commission, all the pneumonias received in this hospital have been typed and careful bacteriological studies made of those coming to autopsy. From July 1 to December 20, which dates include two severe epidemics of the disease, the total mortality rate averaged 19.8 per cent. It is interesting to note the types (pathological) of pneumonia as revealed by the autopsy records. In the first epidemic from July 1 to October 1 there were 34 fatal cases of lobar pneumonia and no fatal cases of lobular pneumonia. In the second epidemic October 1 to December 20 there were 63 cases of lobar pneumonia and 83 of lobular pneumonia coming to autopsy. The average number of days in hospital of the fatal cases was about 7 days
for both types of disease. In the epidemic of pneumonia associated with influenza, type 4 pneumococcus was found in about 70 per cent of the cases. Types 1, 2, and 3 furnished about 20 per cent of the cases, hemorrhagic streptococcus, nonhemolytic streptococcus, and Freidlander's bacillus furnishing the remainder. Attempts have been made in the wards to differentiate clinically between the pneumonias caused by the various organisms, but these attempts have failed, The majority of cases of lobar can be differentiated clinically from lobular pneumonia, but not all. In the latter epidemic, lobar pneumonia has been much more frequently observed among the colored race than lobular pneumonia and vice versa for the white race. This clinical observation has been borne out by the autopsy records. Type 1 pneumonias have been treated with the Cole's antipneumococcus serum. The pneumonia cases have at all times been segregated into special wards and kept there until well into convalescence. In the histories which our ward surgeons have secured the complaint of chilling stands out conspicuously. Recruits admitted to camp and compelled to sleep on cool nights in tents without enough blankets to keep them warm, have furnished the large percentage of pneumonia material for this hospital. A large number of the soldiers with pneumonia had been given pneumococcus vaccine (types 1, 2, and 3) prior to the onset of the disease. While apparently this vaccination afforded protection against these types of organisms it did not protect against pneumonia of the type 4 variety. Neither did it lower the mortality record, since in the epidemic of pneumonia in August, which occurred prior to the vaccination of troops, the mortality rate was 15.7 per cent, while in the epidemic of November and December, after vaccination, the mortality rate was 21.1 per cent. On September 4, 1918, a pneumonia board appointed by the Surgeon General's Office reported at this hospital as a special commission to investigate certain phases of the pneumonia problem and for collecting information concerning the etiology, clinical course, and pathology of pneumonia. They were also to introduce voluntary vaccination against pneumonia of troops in the camp and to determine, if possible, the efficacy of such vaccination. This commission in collaboration with officers at this hospital initiated at once a program for preventing, if possible, an epidemic of influenza at Camp Wheeler. Various measures such as quarantine, face masks, spraying with dichloramine, closing of places of public assembly, etc., were initiated and some or all of these measures were responsible probably for the mild character of the influenza epidemic in this camp. About October 1 the work of vaccinating the camp against pneumonia was started and since that time something over 13,000 troops have received the pneumococcus vaccine. It will suffice to say that the camp has been almost free of types I, II, III pneumonia and the death rate for all pneumonias occurring in camp since October 1, 1918, has been only 19 per cent, about half the rate in many of the camps where influenza was epidemic.
An epidemic of pneumonia was present in this camp during March and April, 1918. Prior to March 3 the admissions of pneumonia had not exceeded 6 cases a day, then steadily increasing, 23 cases being reported in one day the first week in April. The predisposing causes of tins epidemic were climate, new recruits, susceptibility, general sanitation, and discipline. The epidemic was most prevalent in the 366th Infantry and the colored troops in the depot brigade. These men were chiefly from Alabama and the change in climatic conditions, which were very windy and dusty, was highly contributory to the causes of the epidemic. The general sanitation of the area of camp occupied by these troops was very poor and coughing and spitting as well as the close association of troops was another added factor. Four hundred and thirty-two cases of pneumonia were reported to this office during March and April and 132 deaths.
There were two outbreaks of pneumonia during the year at this camp. The first appeared suddenly in August, 1918, and was confined wholly to the members of the draft which had just been received. There were approximately 60 cases with 10 deaths. All were endemic in form and in the successfully typed cases type IV predominated. Tents were furled daily and thoroughly ventilated at night. All tent floors were scrubbed with a disinfectant. Noses and throats of all men were sprayed twice daily with an antiseptic solution. Chaplain and Young Men's Christian Association tents were struck, the chairs, tables, and benches scrubbed and ground wet down with an antiseptic solution, and all indoor assemblies prohibited. Clothing of all pneumonia patients was disinfected. These measures were sufficient to control the disease. The second outbreak occurred during the epidemic of so-called Spanish influenza in the month of October, when 400 cases developed, secondary to influenza,
with 153 deaths. There were approximately 1,000 cases of influenza in the camp during the epidemic of influenza, the control of which was by a strict quarantine of the camp, in which all members of the command were kept therein and civilians kept without. All post exchanges, Young Men's Christian Associations, and theaters were closed, tents were furled and clothing and bedding sunned daily. All assemblages except formations for drill were prohibited and an open-air existence maintained. Sick were masked during transportation to hospital and while awaiting the arrival of ambulances at infirmaries. In the hospital all nurses and attendants were masked and patients placed in cubicles. Noses and throats of all members of the command were sprayed twice daily and men constantly watched and examined daily by medical officers to detect those who were at all ill.
Lobar pneumonia and broncho-pneumonia other than streptococcus origin were persistent problems during the winter of 1917 and 1918, but have presented no more than the usual amount of difficulty in treatment and show a mortality comparable to that in the best civilian hospitals. During the last week in July and first two weeks in August there was a marked increase in the number of cases in the hospital. The increase in pneumonia followed an outbreak of measles at a period of about a fortnight and the curves of the two infections are strikingly similar, hut the point of particular interest in connection with these two increases in infection lies in the fact that practically none of the measle cases developed pneumonia, there being at no time during the period referred to more than two or three cases of measles-pneumonia in the hospital. Practically all of these pneumonias were due to infection with a hemolytic streptococcus and nearly all of them were in newly drafted negroes. Following this decline, the incidence of pneumonia remained normal until the onset of the influenza epidemic in late September, 1918. During the period January to October, 1918, there were only a small number of lobar pneumonia grouped under Type I, so that the amount of serum treatment carried out at this hospital during that period was relatively small. Following the improved media and mouse technique about November 20, Type I and Type II pneumococcus assumed a normal percentage in civil life. Type III is still much lower than normal.
Three distinct types of this disease were encountered at this post at varying periods of the year. During the measles epidemic the streptococcus pneumonias were numerous and prone to develop exudate in the pleura and pericardium. At the same time there appeared primary streptococcus pneumonias, similar in character to those following measles. During the winter months also pneumococcus pneumonias were frequent. The cases were admitted to a receiving ward for pneumonia. They were classified and then distributed according to the cause and severity of the disease. During the month of February half of the pneumococcus pneumonias, Type I, received serum. The results proved eminently satisfactory. But no conclusions can be drawn, inasmuch as only 15 cases were so treated. The cases complicated by pleurisy and empyema were treated as follows: At first an early operation was performed. Later, however, it was considered more advisable to aspirate during the acute stages of the disease and operate when the patient had partly recovered from the toxemia. From April until the influenza epidemic arrived there were isolated cases of pneumonia. Pneumonia following influenza is a distinctly different disease from the type we had earlier in the year, inasmuch as this rarely affects the pleura. Two hundred and twenty-five cases occurred, of whom 74 died. All received functional therapy with emphasis upon two things, namely, thorough alkalization and thorough digitalization. The cases were all collected in special pneumonia wards where the routine treatment was well organized.
The medical service under normal conditions occupies 26 wards with a personnel of 25 medical officers. During, the recent influenza epidemic 50 wards were in actual use and in addition to this many patients occupied the Red Cross and Young Men's Christian Association buildings. At this time the personnel of the medical service was increased to about 60 medical officers. In the first half of the year the common infectious cases were prevalent-mumps, measles, and pneumonia.
During the influenza epidemic it was found, that pneumonia was developing more rapidly among those admitted to wards than among those admitted to the tent groups, so that it was arranged to admit all fresh cases of uncomplicated influenza immediately to tents. In this way it is felt that the pneumonia incidence was somewhat reduced. Fortunately, the weather was fine throughout the epidemic and it was possible to have the sides of these pyramidal tents rolled up at all times, providing an abundance of air. All patients in the tent groups were carefully watched for the onset of pneumonia and were then immediately removed to pneumonia wards where the nursing forces were concentrated. During the convalescence of the pneumonia cases there was established in a tent group in connection with the hospital a convalescent detachment. These men were isolated separately, provided with uniforms and were given graduated exercises, their needs in this respect being carefully studied. This convalescent-pneumonia detachment has been very successful.
In importance of pneumonia outranks all the other diseases mentioned; at no time has there been an absence of cases. The high points in the pneumonia chart have followed shortly after the peaks in the curves of measles and influenza. The first rise being during the early months of the year, up until April, probably a large number of these cases following measles were primary lobar pneumonias. During October and November pneumonia reached its highest point, this being due to the occurrence of influenza; with the subsidence of the latter the former rapidly dropped during December to nearly as low a mark as during any month of the year. Special measures, have included the use of the antipneumococcic serum in the appropriate cases, namely Type I infections, 100 c. c. to 300 c. c. of the serum being used in individual cases, depending upon the indications and progress of the case. The mortality of these cases has been under 10 per cent. The majority of the cases have been due to the various types of pneumococcus, chiefly of the Type IV. During the epidemic of measles and influenza a large number of cases were undoubtedly due to a hemolytic streptococcus and a few to the influenza bacilli.
This camp has not at any time been entirely free of pneumonia, and at three times during the year the number of cases reached epidemic proportion. The first epidemic occurred in January with 61 cases and followed an outbreak of measles. It was complicated in a large percentage of cases by empyema. The mortality of uncomplicated pneumonia in this epidemic was 16.7 per cent and of the pneumonia complicated by empyema was 64.3 per cent. This high mortality was due to the great virulence of the infecting, organism and the very fulminant course of the disease.
The second outbreak of pneumonia occurred during the months of March, April, and May, there being during that time 233 cases. The cases occurring at this time were in a large measure primary pneumonias or secondary to bronchitis, very few cases being secondary to measles. During this period comparatively few cases of measles in camp. Taking the period from March 27 to May 1, 1918, which period included most of the cases in this outbreak, the mortality of uncomplicated pneumonias was 14.3 per cent, while for the 34 cases complicated by empyema the mortality was 50 per cent.
This outbreak was in a large measure due to the entrance into camp of a large increment of Negro recruits from Alabama. These men were insufficiently clothed, their resistance lowered by the long trip and unusual surroundings, and exposure rendered almost certain by their habit of congregating in groups inside the barracks with insufficient ventilation.
This epidemic subsided in May with the beginning of warmer weather and the institution of such preventive measures as the masking of all cases showing catarrhal symptoms, frequent and thorough examination of all the men exposed, and strict guard kept over the ventilation and the prevention of assembling in groups.
From February 24 to September 19, 1918, 441 cases of pneumonia were treated in this hospital. Forty-three cases were admitted in January, 1918, nearly all of which were of the lobar type, and but 2 developed empyema, all with a favorable recovery. Of the 70 cases admitted in February, broncho-pneumonia were in evidence, 11 developing empyema, with 10 deaths. These were all of the hemolytic streptococci type.
Pure pneumococcus pneumonia of Types I, II, and III was comparatively rare. When these organisms were found they were usually complicated by streptococci.
It was difficult to differentiate lobar pneumonias and broncho-pneumonia, for in many instances a confluent broncho-pneumonia showed large, single, or multiple areas of consolidation indistinguishable by physical signs, and only at autopsy could the diagnosis be made with certainty in many cases.