Read by Title to the Tri-State Medical Association of the
Carolinas and Virginia, meeting at Charleston, February 9th and 10th
VIRUS PNEUMONIA (primary atypical pneumonia, non-specific
pneumonitis, epidemic non-bacterial pneumonia, disseminated
focal pneumonia, viral pneumonia) has been accepted as an
entity and has been under observation in this country and
abroad for the past twelve years. No bacteriological studies
have confirmed the etiology of this disease other than by
negative findings. The sputum shows the usual flora of
gram-positive and gram-negative organisms. In 1938,Reimann
reported that a filterable infectious agent was recovered from
the nasopharynx of one and from the blood of another out of a
series of eight cases, but not sufficient evidence could be
found to determine such as the causative factor. It must be
closely allied to the virus causing influenza, because in the
first twenty-four to thirty-six, hours it is very commonly
thought to be that type of infection. Horsfall and his
co-workers at the Rockefeller Institute have cultured an
organism, which they have designated Streptococcus MG, from a
large percentage of their patients with primary atypical
pneumonia. The exact role of this bacterium is not known, but
it is seldom found except in persons ill of this disease. Since
it is not present in all cases, it is not the primary cause,
but only a characteristic secondary invader or associate. The
disease also resembles psittacosis in many respects and since
penicillin might be of value in such cases it is of great
importance to establish the diagnosis quickly.
The onset of this type of virus infection is always gradual.
Like all virus diseases there is a wide variation of the
prodromal symptoms. There might be none; there might be the
classical generalized malaise. This disease is highly
contagious, and our observations over a five-year period point
to a definite incubation period of from five to fourteen days.
We have also noted that the longer the incubation period the
milder the infection: the shorter the incubation period the
more severe is the infection. This must be interpreted in the
first instance as either a mildly virulent organism or a high
degree of resistance or immunity on the part of the host and in
the second instance as a very virulent organism or no immunity
at all on the part of the host. In some instances, however, the
patient will have a slight attack with apparent recovery due
either to good resistance against a weak virus or good response
to treatment only to be followed in seven to ten days by a
return of symptoms in a more severe form and producing a
critically ill patient. This type of case cannot be classified
as a fourteen-day incubation period, but rather it is one in
which the virus was only attenuated or else there has been the
factor of a secondary infection.
The chief complaint, however, will always be one of sudden
onset, since the patient begins his concept of his illness from
the time he first experienced waves of chilly sensations or a
frank chill alternating with hot spells and associated with
burning in the nose, a sore throat, hoarseness, a bad taste in
his mouth, moderate vertigo, nausea and grade-two type frontal
headache. This picture will then develop to the point where
severe frontal headache is noted along with a feeling of
weakness in the lower extremities so marked that the patient
complains of a dragging sensation when moving about in bed.
This weakness persists for some days after clearing of all
symptoms and negative chest films. The patient can hardly
support his body weight without the feeling of buckling at the
knees. Added to the above might be substernal pain or
generalized tightness in the chest with varying degrees of
tracheo-bronchitis. The fever is usually found during this
phase to be about 102°F. After pulmonary involvement of as
much as 6 by 8 cm. areas have been reached the fever will be up
to 103 and 104°F. in adults and up to 105°F. in infants
and early childhood. Dry hacking cough is a most constant
factor especially after the second day of illness. Occasionally
this cough is paroxysmal, and if the invasion is severe enough
it will in the final clearing stage of the disease be thick,
tenacious, brownish-gray — even blood-streaked. This
disease shows remarkable versatility in that it will vary its
symptoms and signs to fit with that of a mild cold on one hand
to a very serious medical complexity on the other. It suggests
sometimes that more than one bacteriologic unit is involved.
The pulse will be increased in a very definite ratio to the
toxic effect of the virus. If the invasion is mild the pulse
rate will be normal even though the fever may be recorded at
103°F. If, however, the invasion is severe, meaning that
physical findings approximating those of a lobar pneumonia
(with or without a definite complicating encephalitis or
meningitis) are present, or with an accompanying pleurisy, then
the pulse rate will be rapid and will follow the temperature
curve. Sweating is common and it is usually very profuse.
Cyanosis and dyspnea occurred only in those patients that had
at least as much as a lobe of lung involvement and where the
fever continued to climb to a 104°F. each night.
The physical findings are limited to the head and chest.
There is marked rhinitis with swelling of the turbinates. The
accessory nasal sinuses are involved; the frontals being the
chief offenders. The tonsil bed is not remarkable but the
lymphoid tissue on the posterior pharyngeal wall is thickened
and edematous and scarlet in color. The vocal cords appear like
those seen in any simple laryngitis. In the lungs diminished
breath sounds with moist and dry rales (sometimes very coarse)
are usually the only evidence of disease. When there are
extensive areas of consolidation the usual dullness to
percussion, tubular breathing and pectoriloquy are present.
The laboratory findings are of little importance. The white
blood count and differential are nearly always within normal
limits. A 6500 white count is typical regardless of the lung
pathology. The sedimentation rate will be normal except in very
acute cases, with cerebral symptoms. The sputum examination is
valuable only in its negative findings.
Chemotherapy may be tried where x-ray facilities are not
convenient or not obtainable. If sulfonamides and/or penicillin
are given for twenty-four to thirty-six hours without response
both should be discontinued and treatment for virus infection
instituted. In our age it requires some measure of boldness to
discontinue these important drugs so early especially with the
patient still running a fever of from 102 to 104°F. In this
case boldness counts.
There is no constant x-ray picture to be found in virus
pneumonia, but some evidence of pneumonitis will nearly always
be present regardless of the physical signs—even when the
physical signs are absent. The chest film will show anything
from extensive consolidation to a patchy and sometimes fleecy
infiltration suggestive of tuberculosis. This patchy form will
be scattered in all diameters of the lung fields. Plates taken
daily or every second to third day will often show the
pneumonic process clearing in some areas while new areas are
developing at other points. The disease begins as an
infiltrative process starting at the hilus, and then. by a
peribronchial route gradually spreading to the interbronchial
regions. Usually there will be an involvement of several
segments of lung comprising several lobes. These isolated
segments soon become confluent, giving the film a smoky
appearance. This process may go on to involvement of an entire
lobe and in many respects look like a lobar pneumonia. The
marked difference lies in the fact even when the density is
massive a streaky background can always be seen; the shadow in
virus pneumonia is never entirely solid. Resolution, either
spontaneous or from some method of treatment may give positive
x-ray films days and even weeks after there has been a complete
The treatment of virus infections, including frank virus
pneumonia, has been for the most part without specific
recommendations. Oppenheimer in 56 cases employed x-rays in doses from
35r to 90r which he states relieved cough and
shortened the course of the disease. Offutt employed 100r
doses daily or every other day, depending
on the severity and response, alternating front and back or
alternating sides if both lungs were involved. None in his
series of twelve cases received over four treatments. Both men
report surprising uniformity in the disappearance of fever and
symptoms after one or two exposures. No unfavorable reactions
occurred in either series. Aminophyllin in doses of three
grains every four hours has been given with varying results in
the belief that it improved the circulation through the lung
fields. We have employed the drug in smaller doses when there
was evidence that the patient had a coexisting coronary
impairment. Since this was given along with the drug of our
choice, ascorbic acid, this paper cannot evaluate its merits.
Multiple transfusions from multiple donors and blood from
patients convalescing from virus pneumonia have also been
The purpose of this paper is to outline a new and different
form of treatment for this type of virus infection which in 42
cases over a five-year period has given excellent results. The
treatment has double merit due to the simplicity of its
schedule. The remedy used was vitamin C (ascorbic acid) given
in massive doses. Since it is common knowledge that there are
definite individual variations in
absorption of vitamin C from the intestinal tract and under
certain pathological conditions still greater variations in the
absorption factors the I. V. and I. M. routes were used. When a
diagnosis of virus pneumonia was entertained the patient was
given 1000 mg. vitamin C intravenously every six to twelve
hours. If it was by chance that a diagnosis was established in
the home the usual initial dose was 500 mg. given in the
gluteal muscle. Subsequent injections were given I. V. because
the injection was thus made painless and the response was
faster. In infants and very small children, however, 500 mg. I.
M. every six to twelve hours was the method of choice. From
three to seven injections gave complete clinical and x-ray
response in all of our cases. The series comprised types of
cases from very slight consolidation to those resembling lobar
pneumonia. Two cases were complicated by cerebral
manifestations. Vitamin C was also given by mouth in one-third
of this series but there was no outstanding difference in the
response. The dosage was from 100 to 500 mg., depending on the
age of the patient, and it was given every four to six hours.
In almost every case the patient felt better within an hour
after the first injection and noted a very definite change
after two hours. Nausea was relieved by the first injection as
was the headache. The heat regulating center showed a quick
response and it was the rule to find a drop of 2°F. several
hours after the first 1000 mg. Penicillin was given in
conjunction with ascorbic acid in five cases. It was our
observation that penicillin had some retarding effect on the
action of vitamin C, since the response was not so rapid and in
one case the results were not obtained until the penicillin was
Supportive treatment was given by forcing fluids,
particularly fruit juices, to tolerance. Soda-water was given
to adults in the amount of four glasses in 24 hours, each glass
containing one teaspoonful sodium bicarbonate. Infants and
children were given this alkaline drink in proportion to age.
The rationale of bicarbonate of soda is based on the findings
and others, that the amount of vitamin C excreted in the urine
may vary according to the acid: alkali content of the diet, a
highly alkaline urine having lower amounts of vitamin C than a
highly acid urine. Codeine sulfate and aspirin were given by
mouth. In adults the dose was codeine 0.5 grain, aspirin 10
grains given every six hours. Infants and children according to
age. Some few patients complained of severe chest pain and some
others of a constricting sensation that they described as
cutting off their breath. These symptoms were relieved by
employing either Numotizine as a plaster or the old-fashioned
mustard plaster. The mustard plaster was made up with cold
water and was applied cold for a period of about 15 minutes.
The proportions used were one part mustard and two parts flour.
The amount of flour used in preparing the plaster for children
was according to age but in no instance was the ratio greater
than one to six. In childhood an expiratory grunt was taken as
an index to use plasters. Oxygen inhalation was not employed
even though cyanosis existed in twelve cases of the series; an
additional injection of 500 mg. of vitamin C was given with
almost spontaneous alleviation of the distressing condition. In
two cases codeine sulfate was given in one grain amounts
because of the weight of the patient. Diet was forced even
though there was no desire to eat.
It is difficult to evaluate the role played by vitamin C
against the virus organism. We have seen ascorbic acid give
response in other types of virus infections but not sufficient
evidence is on hand to state that it is a virus killer. It has
been shown histologically that vitamin C regulates the
intercellular substance of the capillary wall. In the human
body its chief function is concerned with the formation of
colloidal intercellular substances. The intercellular
substances which appear to be regulated by vitamin C are of
mesencyhmal origin—this means the collagen of all fibrous
tissue structure, all non-epithelial cement substances
including the intercellular substance of the capillary wall.
Gothlin found increased capillary fragility in individuals with blood
levels of 1 mg. of vitamin C per liter or less. It must be
remembered too, however, that ascorbic acid has been reported
to function as a respiratory catalyst, aiding cellular
respiration by acting as a hydrogen transport.
Finally we consider the case of the liver in that the
saturation of the blood plasma with vitamin C betters the
detoxifying powers of this organ. It has been known that fever,
toxemia and specific bacteria do act on the vitamin C
concentration of the blood plasma with a lowering effect. Could
it be that, by maintaining a high blood level of this vitamin,
all body tissue is allowed to return to normal in spite of the
existing fever and the presence of the specific organism, and
that, acting as a respiratory catalyst, it enables the body to
build up adequate resistance to the invader?
Virus pneumonia is a true clinical entity. Although it gives
symptoms similar to influenza in the early stage of illness the
virus has not been identified. The onset is gradual and has an
incubation period of five to fourteen days. The usual beginning
is a hanging-on cold or generalized malaise. The chief
symptoms, although not all are necessarily present each time,
are chilly sensations or a single frank chill, followed with
hot spells, burning in the nose, sore throat, hoarseness, bad
taste in mouth, nausea, frontal headache, dry cough at
first—later productive in the clearing phase of the
disease—sweating, and this is usually profuse, normal
pulse unless complicated with cerebral symptoms, pleurisy or a
condition approximating lobar pneumonia when it will be rapid.
Fever is from 100 to 104°F. The physical findings are
inflammation of the turbinates and accessory nasal sinuses,
hypertrophy of the lymphoid tissue on the posterior pharyngeal
wall. Breath sounds are diminished and moist and dry rales are
sometimes present. In extensive consolidation dullness to
percussion, tubular breathing and pectoriloquy are found. The
laboratory findings show the blood picture within normal
limits: the sputum is negative. Sulfonamides and penicillin are
good diagnostic aids since they have no effect on the disease.
The x-ray findings can be anything from negative films through
pneumonitis on to frank consolidation. Vitamin C in doses of
1000 mg. every six to twelve hours for three to seven
injections has been specific to the author. X-ray in doses from
35 to 100r daily, or every second to third day, for not
more than four exposures, aminophyllin and transfusions from
convalescing or multiple donors have some usefulness as
adjuvants in some cases.
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Roentgenology, 49, No. 5.
- REIMANN, H. A.: An Acute
Infection of Respiratory Tract with Atypical Pneumonia.
Jour. A. M. A., 111: 2377, 1938.
- OFFUTT, V. D.: Diagnosis and
Treatment of Primary Atypical Pneumonia. Southern Med.
& Surg., Jan., 1944.
- SEEDS, E., and MASER, M. L.: Virus Pneumonia. Am. J.
Roentgenology, 49:30-38, 1943.
- REIMANN, H.A.. and HAVENS, W. P.: An Epidemic Disease
of the Respiratory Tract. Arch. Int. Med., 65:138,
- DINGLE, J. H.: Primary Atypical Pneumonia. Amer. J.
Pub. Health, 34:347, 1944.
- Current Concepts of Pneumonia. Scope, Jan.,
- HAWLEY, ESTELLE E., FRAZER,
J. P., BUTTON, L. L., STEVENS, D. J.: The Effect of
the Administration of Sodium Bicarbonate and of Ammonium
Chloride on the Amount of Ascorbic Acid Found in the Urine.
J. Nutrition, 12:215, 1936.
- GOTHLIN, G. F.: A Method of
Establishing the Vitamin C Standard of Requirement of
Physically Healthy Individuals by Testing the Strength of
- A Symposium of the Vitamins. Amer. Med. Assn.,
IMPORTANT: Information provided is intended for educational purposes and is not intended to be medical advice nor offered as a prescription, diagnosis or treatment for any disease, illness, infirmity or physical condition. Always consult your own medical provider about your health and medical questions before making any health related decision. These statements have not been evaluated by the Food & Drug Administration.