This is a transcript of a US Army document published in 1918. I have marked what I think are the most important points in bold. It provides many lessons about managing infection without antibiotics. I will publish a commentary next week (which will bump the HIV article back another week - sorry :-)).
PNEUMONIA - ITS PREVENTION AND MANAGEMENT
EXCERPTED FROM APPENDIX: THE MEDICAL DEPARTMENT OF THE UNITED STATES ARMY IN THE WORLD WAR.
VOLUME II: ADMINISTRATION, AMERICAN EXPEDITIONARY FORCES.WASHINGTON, D.C.: GOVERNMENT PRINTING OFFICE, 1927.
The present epidemic of respiratory infection in the American Expeditionary Forces is largely influenzal in character, with a rather high incidence of secondary pneumonia due usually to pneumococci or streptococci and occasionally to influenza bacilli and possibly to meningococci. The mortality has been in the neighbourhood of 30 per cent. As primary pneumonia is likely to increase with the advent of colder weather, medical officers are reminded that the prevalence of pneumonia, as well as of other respiratory infections, in armies in the field depends particularly upon:(1) Overcrowding.
(2) Exposure to wet and cold.
(3) Fatigue, whether induced by overwork, a long journey, loss of sleep, or nervous exhaustion from worry.
Crowding forces the occupants in barracks or billets into close personal contact, and the greatest danger from it in relation to the occurrence and spread of respiratory infections is obviously in the increased opportunity furnished for droplet infection of the healthy inmates from those who already harbor pathogenic micro-organisms in their noses or throats.
In epidemics of pneumonia or of influenza, the disease is undoubtedly usually spread from man to man through the secretions or discharges from the mouth, nose, or other parts of the respiratory tract, and an individual who harbors virulent pneumoccoci or streptococci or influenza bacilli is obviously very likely to infect his cosleepers by coughing or sneezing, or even speaking loudly in close proximity to them.
In the present epidemic, the great majority of the cases of pneumonia are secondary to influenza—the natural resistance of the individual having been first broken down by this disease, secondary infection of the respiratory tract with pneumococci or streptococci has occurred.
In Panama, where climatic conditions were not severe, pneumonia was prevalent, particularly on account of overcrowding, and the same was found to be true among the workers in the South African mines. Prevention consisted particularly iii scattering the individuals and giving them separate dwellings in place of barracks.
Overcrowding
In relation to overcrowding, Medical War Manual No. 1, for 1917, authorized by the Secretary of War under the supervision of the Surgeon General and Council of National Defense, states that whenever possible the floor space per enlisted man should be 80 square feet, affording 960 cubic feet, and should never be less than 10 by 6 feet, or 60 square feet, which with a ceiling 12 feet high would afford 720 cubic feet. This manual further states that should an epidemic occur and should the soldiers be overcrowded, it may be assumed axiomatically that the epidemic can not be checked by other sanitary measures alone, but must be combined with measures to relieve the overcrowding. Owing to the shortage of lumber and materials, it was thought necessary in the American Expeditionary Forces to reduce the space per man to 1 linear foot, or 20 square feet—one-third of the minimum amount recommended. The order directs that bunks shall be 2 feet 8 inches wide by 6 feet 6 inches, double tier, in sets of four, 2 feet 8 inches apart, giving 1 linear foot of Adrian barracks per man. It is hoped that conditions will soon be such that this allowance may be increased. In the meantime, an effort must be made to prevent droplet infection by other means between the men sleeping side by side in barracks. A board partition 2 feet high may be built between the two adjoining bunks, Until this is done, wires may be run 2 feet above the bunks and the shelter tents suspended upon them between the adjoining bunks, Similar precautions should be taken in billets and tents. This is a more practical arrangement than placing the head to the feet of the adjacent sleeper. In cases where the overcrowding is excessive and the weather fine, the advisability of bivouacing the men in the open air under shelter tents, or other canvas, should be considered, If this is done, additional blankets obviously should be supplied. Relief from the dangers of overcrowding should be the first important consideration in connection with the checking of the present epidemic. Distance between beds is the important factor, not cubic space, in the prevention of the spreading of pneumonia infections, Crowding in recreation rooms at cinematograph entertainments, etc., should at present time be prevented as much as possible.
Wet and cold
Wet and cold are also important predisposing factors in pneumonia epidemics. A lowered condition of vitality from cold favors particularly the development of such infectious diseases as pneumonia and influenza, by lowering the resistance of the bronchial and pulmonary tissues to infection. Experiments suggest that infections with these diseases are favored by cold and chilling through the stimulation of the mucous glands with resulting closure of the small bronchioles with plugs of mucus. It is well known that the functions of the leucocytes are disturbed by cold, and it seems likely that phagocytosis may play an important role in connection with the mechanism of immunity in pneumonia, and that immunity is in this disease particularly related to the functions of the leucocytes. The movements and phagocytic action of the leucocytes occur ~most favourably at about the temperature of the normal body. Exposure of the skin to cold and wet leads to chilling of the leucocytes during their repeated passage through the skin capillaries, which may diminish their functional activity, and thus lower resistance to a point at which infection may occur. It should be borne in mind that cold wet feet produce a general reaction of the body and not only a local one, and that this condition also predisposes to infection. Cold and wet have less unfavorable action when accompanied by energetic muscular exercises, if a condition of fatigue is not reached. Additional efforts should be made to provide for the prompt removal and drying of the wet clothing of the soldier, and additional blankets at night must be insisted upon.
Fatigue
It should be borne in mind that fatigue induced by overwork and also by lack of sleep and worry in connection with wet and cold has been one reason for the excessive mortality from pneumonia in armies in the field. It is well known that normal resistance to infection may be broken down by fatigue.
Early detection
Greater attention should be paid by medical officers to the early discovery of cases of colds, cases of influenza, and other respiratory infections, and to prompt isolation and treatment of such cases. Carriers undoubtedly play an important role in disseminating pneumocoeci, streptococci, and influenza bacilli as well as meningococci.
Warning against spitting
Men should be specifically instructed at this time against expectorating in quarters, and the danger of sneezing and coughing and of speaking in close proximity to the face explained.
THE MANAGEMENT OF PNEUMONIA
1. Pneumonia, especially as it occurs among troops, and as it is now present in the American Expeditionary Forces, must be regarded as a highly contagious disease, and it must be managed with the same precautions as are taken in the care of other contagious diseases.
2. The epidemics of influenza now prevalent in many widely separated parts of France have at least one point in common; i. e., the occurrence of pneumonia as an incidence of the disease, a complication, or a sequel. The pneumonia is usually of a patchy type, different slightly in its characteristics in different regions, but characterized by rapid progress, great respiratory distress, frequency of early collapse, and high mortality. The causative organism may not always be the same; pneumococcus, streptococcus, and the influenza bacilli and occasionally the meningococcus all seem to contribute their share.
3. Early isolation and hospitalization of pneumonia as well as of influenza and similar respiratory infections will do much to prevent the spread of the disease and lower the mortality. Cases should be hospitalized, when possible in medical formations where they may remain until recovery, even though the initial trip by ambulance may be somewhat lengthened. Cases of pneumonia in the earliest stages withstand transportation fairly well, but later in the disease after they are hospitalized, they are greatly injured by moving. Numerous cases of respiratory infections have been evacuated by train or by motor, to arrive at their destination some hours later in profound collapse, to die within a very short time. Moving a case of pneumonia to make room for a battle casualty may kill the pneumonia patient and not aid the wounded, and the practice should not be tolerated.
4. Isolation or segregation should be practised in all cases of respiratory infection and such isolation should start in the field. Upon arrival at the hospital the cases of respiratory infection should be received in wards devoted to the observation of cases with respiratory infection; or if it is possible to make an absolute diagnosis on admission to the hospital, the case may be sent directly to the ward designated to receive cases suffering from that particular type of infection. The observation ward for respiratory diseases should be cubicled, a sheet or other partition being placed between adjacent beds. It is desirable that an accurate diagnosis be made as soon as possible of cases in this ward so that they may be transferred immediately to those wards designated to receive cases suffering from the different types of respiratory infection. All cases of uncomplicated influenza should be isolated in separate wards as rigidly as if they were cases of measles, and all beds should be cubicled. No cases of pneumonia should be sent to these wards, and should a patient with influenza develop pneumonia he should be immediately removed to a pneumonia ward. Cases of pneumonia should be segregated in wards set aside for this purpose. These wards should be cubicled. The reason why such rigid isolation and employment of the cubicled system is imperative is due to the fact that, first, cases of influenza are highly susceptible to pneumonia and may be infected with great readiness by a pneumonia patient in the near proximity, and, secondly, that the lobular type of pneumonia may be caused by several varieties of organisms, and should a patient with a pneumococcal pneumonia be placed next to one with a streptococcus pneumonia either one or both patients might readily contract a double infection. The course of the disease in such double infections is much more serious and the mortality much higher than in single infections. Cross infections will, therefore, be less common and the mortality reduced by cubicle isolation for all respiratory infections. The practice of receiving respiratory infections of unknown origin in wards with other medical or surgical cases is reprehensible and is responsible for many fatal cases of pneumonia in individuals who might otherwise have been returned to duty within a short time. Cubicle isolation may most readily be carried out by screening with sheets. This can be done by posts and the use of wire and can be adapted for tents as well as for wards. It is only necessary that the screen should reach midway between the foot and head of the bed, halfway between the bed and the floor, and 2 1/2 to 3 feet above the level of the patient. It is, however, highly important that the screen should extend several inches beyond the head of the bed.
5. Protection of medical officers, nurses, and personnel with gowns and fresh and clean gauze masks is important, both to prevent spread of infection among them and to prevent their transmitting infection to others. Attendants should be examined with the view to finding carriers: When found, these should be disinfected. Masking of all individuals who come in contact with cases of respiratory infection and fever, except in case of extreme urgency, and then only with precautions to prevent the transmission of the disease to others. Patients should be masked while being moved.
6. Special attention must be paid to all cases of respiratory infection, with fever with relation to the development of signs of pneumonia. It is often impossible at the outset to distinguish between cases of influenza, without consolidation, and actual pneumonia, All cases, with fever and with symptoms referable to the respiratory tract, must be viewed with suspicion and hospitalized, and the physical signs must be carefully watched.
7. Bacteriological examination in order to determine the infecting organism is important, not only from the standpoint of specific therapy, hut also to facilitate the management of cases of different aetiology. It must be remembered that pneumonia is really a group of diseases, with certain common signs and symptoms. The promiscuous mingling of cases of pneumonia, without determination of the infecting organism, is as harmful as the mingling of measles, scarlet fever, and smallpox.
8. Specific therapy, when possible, is advisable. This will at present be limited to cases of pneumonia due to pneumococcus, type 1. The indiscriminate use of serum, without proper type determination, is ill-advised, not only on account of the fact that it subjects the patient to unnecessary inconvenience, discomfort, and possibly danger, but on account of the fact that serum is scarce, and must be saved for the cases in which it is actually indicated. The polyvalent serum may be used in type 1 cases, as its titer for the type 1 organism is as high as that of the monovalent type I serum. The use of polyvalent serum in cases other than those due to pneumococcus, type 1, is not advised.
9. General treatment should be directed toward sustaining the patient and guarding against collapse. Under no circumstances should a patient with pneumonia, or suspected of having pneumonia, be allowed to walk, and after he is put to bed he should not be permitted to sit up for any reason whatsoever, He must be kept warm, but must be assured a continuous supply of fresh air. Fluids should be given freely from the start, and the patient should be induced to take them frequently and in considerable amounts. Sponge baths should be used to combat high temperatures.
10. Early cyanosis and collapse are characteristic of the present form of pneumonia. Treatment aimed to prevent and to combat circulatory failure should be instituted promptly on making the diagnosis of pneumonia. The early use of digitalis has been shown to reduce mortality, and is advised. It may be given in the form of a standard tincture, of which a total amount of 30 c. c. (1 fluid ounce) should usually be given. The following schedule may be followed.
If seen on the first or second day:
[table]
If seen on the third day, or later:
[table]
The hospitals should supply themselves with a standard tincture of digitalis. Do not use pills which are insoluble. Other stimulants, notably citrated caffeine and camphorated oil, may be used by hypodermic injection when collapse occurs or is imminent. The use of strychine has not been shown to be of value.
11. Morphine is of great value to control severe coughing, to relieve the pain of pleuntis, and to secure rest for the patient. It should be used without hesitation. For the troublesome tympanites that frequently occur, turpentine stupes, given while a small catheter is inserted in the rectum, are of value.
12. Most careful attention must be paid to the physical signs, particularly with relation to spread of the consolidation and to fluid in the chest. When the physical signs suggest fluid exploratory puncture, the microscopic and bacteriological examination of the fluid obtained should be performed promptly. Exploratory respiration is a simple procedure, with little, danger or discomfort to the patient. Local anesthesia may be induced by freezing or by intracutaneous and subcutaneous injection of cocaine or novocaine. When clear or even slight turbid fluid is obtained, even when the infecting organisms are demonstrated in the fluid, treatment by repeated aspiration with the Potain aspirator is followed by the best results, When purulent fluid is found, or in cases where fluid previously clear becomes purulent, operation is advised, with postoperative measures. necessary to insure free drainage.
13. Convalescence must be managed with care, both as to the condition of the patient and as to his transmitting the disease to others. Development of pleural exudate late in the disease, or during convalescence, is not uncommon, and frequent physical examination must not be neglected. Relapse or spread may also occur after the temperature has been normal for several days, and the patient should not be permitted to sit up or move about until 7 to 10 days have elapsed. During this period isolation should be practiced as during the acute stage of the disease. The use of mildly antiseptic solutions in the mouth and nasal passages is of value in reducing the number of carriers. Patients should not be allowed to mingle with other patients, and should not be evacuated until all signs of infection of the respiratory tract have disappeared.
14. Recovery and return to duty will be slow. The final stages of recovery will best be provided for in convalescent camps. No patient who has had pneumonia should be evacuated to a convalescent camp until his temperature has been normal for at least two weeks, and in cases where the infection has been severe or prolonged this period will be materially increased, The patient should be free from cough and other physical signs should be normal.
WALTER D. McCAW,
Colonel, Medical Corps, Chief Surgeon.
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