Part 24

Abrahams, Hallows and French Lancet., 1919; i, p. 1. Abrahams, Hallows, Eyre and French Lancet., 1917; ii, p. 377. Abstract of Foreign Literature on Influenza Jour. A. M. A., 1918; lxxi, p. 1573. Adrian Quoted by Tedesko, q. v. Allen Lancet., 1910; i, p. 1263. Averill, Young and Griffiths British Med. Jour., 1918; ii, p. 111. Avery Jour. A. M. A., 1918; lxxi, p. 2050. Babes Deutsch. Med. Wochen., 1892; xviii, p. 113. Batten Lancet., 1910; i, p. 16. Basile Baumgarten Jahresb., 1907; xxiii., p. 284. Beall Jour. A. M. A., 1906; xlvi, p. 1442. Bernstein and Loewe Jour. Infect. Dis., 1919; xxiv, p. 78. Besancon and Griffon Quoted by Scheller, q. v. Besson Text-book, translated by Hutchens, 1913. Blanton and Irons Jour. A. M. A., 1918; lxxi, p. 1988. Boggs Amer. Jour. Med. Sci., 1905; cxxx, p. 902. Brem, Bolling and Casper Jour. A. M. A., 1918; lxxi, p. 2138. Brentz and Frye Woman’s Med. Jour., 1908; xviii, p. 73. Brown and Orcutt Jour. Exper. Med., 1918; xxviii, p. 659. Bruschettini Cent. f. Bakt. Abt. i., 1892; xi, p. 412. Bruschettini Cent. f. Bakt. Abt. i., 1892; xii, p. 34. Bruschettini Cent. f. Bakt. Abt. i., 1893; xiv, p. 253. Bujivid Cent. f. Bakt. Abt. i., 1893; xiii, p. 554. Canon Die Bakteriologie des Blutes bei Infektionskrankheiten Jena, 1905. Canon Deutsch. Med. Wochen., 1892; xviii, p. 28. Cantani Zeit. f. Hyg., 1896; xxiii, p. 265. Cantani Cent. f. Bakt. Abt. i., 1897; xxii, p. 601. Cantani Cent. f. Bakt. Abt. i., 1900; xxviii, p. 743. Cantani Zeit. f. Hyg., 1901; xxxvi, p. 29. Cantani Cent. f. Bakt. Abt. i., Orig., 1902; xxxii, p. 692. Cantani Zeit. f. Hyg., 1903; xlii, p. 505. Capaldi Cent. f. Bakt. Abt. i., 1896; xx, p. 800. Clemens Munchen. Med. Wochen., 1900; p. 925. Cohen Annales de l’Instit. Pasteur., 1909; xxiii, p. 273. Cohen and Fitzgerald Cent. f. Bakt. Abt. i., Orig., 1910; lvi, p. 464. Cohn Arch. f. Gyn., 1907; lxxxii, p. 695. Cohn Cent. f. Bakt. Abt. i., ref., 1906; xxxviii, p. 23. Cole and MacCallum Jour. A. M. A., 1918; lxx, p. 1146. Cornil and Chantemesse Cent. f. Bakt. Abt., i., 1893; xiii, p. 489. Couret and Herbert Report at meeting of Amer. Assoc. Path. and Bact., 1919. Coutant Jour. A. M. A., 1918; lxxi, p. 1566. Davis, D. J. Jour. Infect. Dis., 1907; iv, p. 73. Davis, D. J. Arch. Int. Med., 1908; ii, p. 124. Davis, D. J. Jour. Infect. Dis., 1910; vii, p. 599. Davis, D. J. Amer. Jour. Dis. Child., 1911; i, p. 249. Davis, D. J. Jour. A. M. A., 1915; lxiv, 1814. Davis, D. J. Jour. Infect. Dis., 1917; xxi, p. 392. Delius and Kolle Zeit. f. Hyg., 1897; xxiv, p. 327. Dever, Boles and Case Jour. A. M. A., 1919; lxxii, p. 265. Dick, G. F. Jour. A. M. A., 1918; lxx, p. 1529. Dick, G. H. and Murray Jour. A. M. A., 1918; lxxi, p. 1568. Dujarric de la Riviere Jour. Med. Res., 1918; xxxix, p. 39, review. Dunn Jour. A. M. A., 1919; lxxi, p. 2128. Ecker Jour. A. M. A., 1918; lxxi, p. 1482. Ely, Lloyd, Hitchcock and Nickson Jour. A. M. A., 1919; lxxii, p. 24. Eyre Jour. Path. and Bact., 1909; xiv, p. 160. Eyre and Lowe Lancet., 1918; ii, p. 484. Ferry Jour. Path. and Bact., 1915; xix, p. 488. Fichtner Cent. f. Bakt. Abt., i, Orig., 1904; xxxv, p. 374. Fichtner Baumgarten’s Jahresb., 1906; xxii, p. 207. Finkler Cent. f. Bakt. Abt., i, 1896; xx, p. 807. Fleming, A. Lancet., 1919; i, p. 138. Fleming, J. S. Jour. A. M. A., 1918; lxxi, p. 2137. Fraenkel Quoted by Howard, q. v. Friedberger Cent. f. Bakt. Abt., i, Orig., 1903; xxxiii, p. 401. Friedlander, McCord, Sladen and Wheeler Jour. A. M. A., 1918; lxxi, p. 1652. Ghedini and Breccia Cent. f. Bakt. Abt., i, Ref., 1911; lvii, p. 567. Ghedini and Fedeli Cent. f. Bakt. Abt., i, Ref., 1910; xlvii, p. 358. Ghedini Baumgarten’s Jahresb., 1906; xxii, p. 207. Ghedini Cent. f. Bakt. Abt., i, Orig., 1907; xliii, p. 407. Ghon and Preyss Cent. f. Bakt. Abt., i, Orig., 1902; xxxii, p. 90. Ghon and Preyss Cent. f. Bakt. Abt., i, Orig., 1904; xxxv, p. 531. Giani and Picchi Cent. f. Bakt. Abt., i, Ref., 1906; xxxvii, p. 239. Gioelli Cent. f. Bakt. Abt., i, 1898; xxii, p. 853. Goodpasture Jour. A. M. A., 1919; lxxii, p. 724. Gotch and Wittingham British Med. Jour., 1918; ii, p. 82. Grassberger Zeit. f. Hyg., 1897; xxv, p. 453. Grassberger Cent. f. Bakt. Abt., i, 1898; xxiii, p. 353. Greenwood British Med. Jour., 1918; ii, p. 563. Gregor British Med. Jour., 1919; i, p. 242. Guiral Reviewed Jour. A. M. A., 1919; lxxii, p. 80. Guizzetti Reviewed Jour. A. M. A., 1919; lxxii, p. 1111. Hammond, Rowland and Shore Lancet., 1917; ii, p. 41. Harris Lancet., 1918; ii, p. 877. Heyrovsky Wien, Klin. Woch., 1904; xvii, p. 644. Hicks and Gray Lancet., 1919; i, p. 419. Hill, Leonard British Med. Jour., 1919; i, p. 238. Holman Jour. Infect. Dis., 1914; xv, p. 293. Holman Jour. Med. Res., 1916; xxxv, p. 151. Horder Lancet., 1918; ii, p. 871. Horder 36th An. Rep. Loc. Govt. Bd., 1906; p. 279. Howard and Ingersoll Amer. Jour. Med. Sci., 1898; cxv, p. 520. Huntoon Report at meeting of Amer. Assoc. Path. and Bact., 1919. Hurley Letter. Boston Med. Surg. Jour., 1918; clxxix, p. 691. Huyghe Quoted by Scheller, q. v. Influenza Committee Advis. Bd. to the D. G. M. S. British Med. Jour., 1918; ii, p. 509. Jacobsohn C. r. Soc. Biol., 1901; xix, p. 553. Jehle Quoted by Madison, q. v. Jochmann Cent. f. Bakt. Abt. i, Ref., 1906; xxxviii, p. 661, and quoted by Scheller, q. v. Jordan Jour. A. M. A., 1919; lxxii, p. 1542. Keegan Jour. A. M. A., 1918; lxxi, p. 1051. Keeton and Cushman Jour. A. M. A., 1918; lxxi, p. 1962. Kinsella Jour. A. M. A., 1919; lxxii, p. 717. Kitasato Deutsch. Med. Wochen., 1892; xviii, p. 28. Klein British Med. Jour., 1892; p. 170. Klieneberger Quoted by Scheller, q. v. Koch Quoted by Davis, 1915; q. v. Kossel Quoted by Ritchie, q. v. Kotz Jour. Lab. Clin. Med., 1919; iv, p. 424. Krage Baumgarten’s Jahresb., 1910; xxvi, p. 1063. Kraus Jour. A. M. A., 1919; lxxii, p. 292. Medical News. Kretz Cent. f. Bakt. Abt., i, 1898; xxiii, p. 24. Krumbhaar Lancet., 1918; ii, p. 123. Lacy Jour. Lab. and Clin. Med., 1918; iv, p. 55. Lamb and Brannin Jour. A. M. A., 1919; lxxii, p. 1056. Latapie C. r. Soc. Biol., 1904; lv, p. 1272. Latapie Jour. Med. Res., 1918; xxxix, review. Levinthal Zeit. f. Hyg., 1918; lxxxvi, p. 1. Libman Trans. Assoc. Amer. Phys., 1912; xxvii, p. 157. Lindenthal Wien. Klin. Wochen., 1897; x, p. 353. Little, Garofalo and Williams Lancet., 1912; ii, p. 34. Longo Baumgarten’s Jahresb., 1908; xxiv, p. 660. Lord Boston Med. and Surg. Jour., 1902; cxlvii, p. 662. Lord Boston Med. and Surg. Jour., 1905; clii, pp. 537 and 574. Lord Jour. Med. Res., 1908; xix, p. 295. Lord, Scott and Nye Jour. A. M. A., 1919; lxxii, p. 188. Luerssen Cent. f. Bakt. Abt., i, Orig., 1904; xxv, p. 434. MacCallum Monog. of Rockefeller Instit. for Med. Res., 1919; No. 10. Macdonald and Lyth British Med. Jour., 1918; ii, p. 488. Macdonald, Ritchie, Fox and White British Med. Jour., 1918; ii, p. 481. Madison Amer. Jour. Med. Sci., 1910; cxxxix, p. 527. Madison Jour. A. M. A., 1910; lv, p. 477. Mann, Rainaford and Warren Med. Surg. Rep. of Roosevelt Hosp., 1915. Martin, C. J. . British Med. Jour., 1918; ii, p. 281. Matthews Lancet., 1918; ii, p. 104. Medalia Boston Med. Surg. Jour., 1919; clxxx, p. 323. Menko Quoted by Scheller. Menschikow Cent. f. Bakt. Abt., i, Ref., 1906; xxxvii, p. 490. Meunier Cent. f. Bakt. Abt., i, 1897; xxi, p. 689. Meunier La Sam. Med., 1898. Quoted by Lord and Scheller, q. v. Minaker and Irvine Jour. A. M. A., 1919; lxxii, p. 847. Mix New York Med. Jour., 1918; cviii, p. 709. Moon Quoted by Davis, 1915; q. v. Moszkowski Cent. f. Bakt. Abt., i, Ref., 1902; xxxii, p. 272. Munro British Med. Jour., 1919; i, p. 338. Muir and Wilson British Med. Jour., 1919; i, p. 3. McMeekin Reviewed Jour. A. M. A., 1919; lxxii. McPhedran Canadian Med. Assoc. Jour., 1913; iii, p. 548 Nastjukoff Cent. f. Bakt. Abt., i, 1895; xvii, p. 492. Nichols and Stimmel Jour. A. M. A., 1919; lxxii, p. 174. Norris and Pappenheimer Jour. Exper. Med., 1905; vii, p. 450. Nuzum, Pilot, Stangl and Bonar Jour. A. M. A., 1918; lxxi, p. 1562. Odaira Cent. f. Bakt. Abt., i, Orig., 1911; lxi, p. 289. Oertel Canadian Med. Surg. Jour., 1919; ix, p. 339. Opie, Freeman, Blake, Small and Rivers Jour. A. M. A., 1919; lxxii, pp. 108 and 556. Orticoni and Barbie Reviewed Jour. A. M. A., 1919; lxxii, p. 228. Orticoni, Barbie and Leclerc New York Med. Jour., 1918; cviii, p. 730. Paltauf Wien. Klin. Wochen., 1899; xii, p. 576. Paranhos Cent. f. Bakt. Abt., i, Orig., 1909; l, p. 607. Park Reported at Meeting of Amer. Assoc. Path. and Bact., 1919. Parker Jour. A. M. A., 1919; lxxii, p. 476. Patrick Lancet., 1919; i, p. 137. Pfeiffer Deutsch. Med. Wochen., 1892; xviii, p. 28. Pfeiffer Zeit. f. Hyg., 1893; xiii, p. 357. Pfeiffer and Beck Deutsch. Med. Wochen., 1893; xviii, p. 465. Pieliche Berl. Klin. Wochen., 1894; xxxi, p. 534. Poliak Wien. Klin. Wochen., 1908; xxi, p. 973. Pritchett and Stillman Jour. Exper. Med., 1919; xxix, p. 259. Rapaport Jour. A. M. A., 1919; lxxii, p. 633. Richards and Gurd Montreal Med. Jour., 1907; xxxv, p. 541. Richter Cent. f. Bakt. Abt., i, 1894; xxxi, p. 832. Ritchie Jour. Path. and Bact., 1911; xiv, p. 615. Rivers Bull. Johns Hopkins Hosp., 1919; xxx, p. 129. Robertson, H. E. Jour. A. M. A., 1918; lxx, p. 1533. Robertson, W. F. British Med. Jour., 1918; ii, p. 680. Rosenow Jour. A. M. A., 1919; lxxii, p. 1604. Rosenthal These. Paris., 1900. Rucker and Wenner New York Med. Jour., 1918; cviii, p. 1066. Saathoff Munch. Med. Wochen., 1907; p. 2220. Sacquepee Paris Med., 1913; xxxv, p. 208. Sahli Reviewed Jour. A. M. A., 1919; lxxii, pp. 686 and 111. Scheller Cent. f. Bakt. Abt., i, Orig., 1909; l, p. 503. Scheller Kolle and Wassermann, 1912; v, p. 1257. Schlagenhaufer Quoted by Scheller, q. v. Schofield and Cynn Jour. A. M. A., 1919; lxxii, p. 981. Schultes Quoted by Scheller, q. v. Slatineanu C. r. Soc. Biol., 1901; xxix, p. 850. Slatineanu Cent. f. Bakt. 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THE PATHOLOGY OF EPIDEMIC INFLUENZA

By OSKAR KLOTZ, M. D., C. M.

The discussion to be entered into in this report will be limited to an experience dealing with epidemic influenza as it was met with in the emergency Military Hospital in Pittsburgh. We shall largely confine our attention to the observations which came directly under our supervision, and in as much as this investigation was continued during the epidemic as it swept over this district, the intensive study was limited to a time period of about five weeks. During this period much material was collected, which since then, has taken us a considerable time to analyze. We have thought it more valuable to restrict our discussion to this material in that it illustrates the pathological lesions as they occurred during the acute stage of the disease. We have not entered upon a discussion of the sequelæ or the chronic lesions which are not uncommonly found following in the wake of an acute epidemic nor do we deal with the lesions arising in cases of sporadic influenza, such as are always with us. As is so well illustrated in the literature, there is probably no disease which has so many late complications and sequelæ as influenza. The investigations upon the protean lesions have been fully reported in numerous papers during the intervals between epidemics. A comprehensive bibliography upon influenza will be found at the end of the extensive report by Leichtenstern (1905). There is very much less accurate information available upon the actual lesions present during the acute disease when present in epidemic or pandemic form, than upon the many clinical complications in various systems and organs. In fact, our knowledge of the pathology of influenza lies more largely in the field of associated lesions such as the late events in the bronchi, the sinuses of the head, abscesses, meningitis and other conditions, rather to be viewed as complications than as portions of the disease. There are relatively few thorough pathological analyses of the influenza lesions as they are found in the acute epidemic disease.

A fair literature has already appeared upon epidemic influenza from the many countries and regions over which the present pandemic (1918) has swept. These reports by various authors are offered from different viewpoints, some investigators being impressed with certain features which they bring into marked prominence in their reports. It thus happens that up to the present there is a decided lack of uniformity in the opinions expressed upon different phases of the subject. The nature of the pathology of the past epidemic has given rise to many expressions of opinion as well as dogmatic statements, which are found to differ from those of others. It seems to us that this apparent confusion arises partly through the somewhat different characteristics of the disease as it has made its appearance in different centers. We hear it repeatedly stated that the types found in different military camps and urban communities were quite unlike those of other regions. It is evident that such differences in the clinical course actually did exist and that the epidemic though having a common foundation upon which the disease process was built differed in what might be looked upon as symbiotic complications during the early and acute stages. Differences in the nature of the findings in various communities also probably lay in the fact that the bacterial flora associated with the causative agent of influenza was quite different in different regions. We mention this here so that a full appreciation will be obtained for the differences in the pathological characters of the disease as they are found in one region or another. We appreciate, of course, that if the concomitant bacterial flora associated with the underlying cause of influenza, differs in different regions, so, too, will the bodily reactions differ within certain degrees. We are becoming more familiar with different types of bacteria, and the resulting inflammatory reaction which is often unique or at least particular, and that not uncommonly the nature of the inflammatory process suggests the type of bacterium involved. This argument, of course, must not be driven too far, for we well know that the same micro-organisms under different conditions can cause types of inflammatory reactions wholly divergent.

In as much as our observations are confined to a particular group of cases and the study of these was undertaken during the five weeks of the acute epidemic, these results are not to be compared with the collected statistics on influenza as they shall be made over a period beginning with the onset of the epidemic and ending with the last vestiges remaining after months or it may be years of time. Our observations are to be considered only in the light of the events taking place during the height of an epidemic wave. In as much as influenza presents itself during an epidemic in different forms, we shall again mainly limit the report upon our investigations of those cases having respiratory lesions. Our acute observations were made upon the tissues of those who had died of this disease. It is impossible, or nearly so, to fully study the tissues of those with lesser lesions and who recover. Hence, if we divide the influenza cases into those (1) without pulmonary lesions and (2) those with pulmonary lesions, we must state that all of our cases coming to autopsy fall in the second group. It is true that one of these having pulmonary lesions was not brought to his fatal termination by them but by a septicæmia arising in the middle ear. He had distinct lesions in his lungs. In other words, our autopsy material represents epidemic influenza in which the lung was definitely involved in an inflammatory state. In all but one of these the pulmonary lesion was the cause of death.

No doubt, if opportunity had presented itself to follow a large epidemic through months of its progress, during which late complications in various portions of the body would make their appearance, our analysis would give a different picture and the pulmonary factor for the fatal termination would not be in such prominence.

Of the first group, those cases of epidemic influenza not showing pulmonary lesions, we will have very little to say, in as much as the pathological investigations of them is impossible, or nearly so, during the height of the disease.

Such cases apparently do not die at this period. I am willing to admit that individuals without pulmonary involvement may succumb, but I question whether their death has been due to the result of the influenzal lesions, be it in nose, pharynx, larynx or trachea, or be it in the intestine, but rather that the fatal termination occurred later in the course of this complex disease, when distant vital organs became involved or incapacitated in a toxemia or secondary bacterial invasion. We must clearly distinguish these cases from the clear-cut ones of epidemic influenza, looking upon the new circumstances as complications aside from the original disease. Such, for example, is the case we have mentioned where a fatal streptococcus bacteriæmia followed in the wake of an otitis media. In our experience we have not had a fatal case of the acute epidemic disease in which the lung was not involved.

In types of epidemic disease such as we have just had, where the epidemic wave has passed over in a period of four or five weeks, there is always much to be regretted which has been left undone. We tried as far as possible to gain all the information available at the time of collecting our materials and of laying aside such of the work which could be accomplished at a subsequent date. The materials were collected from divergent sources in the cadaver, and the more perishable substances were analyzed immediately. During the period of the epidemic 32 autopsies were performed and as much use as possible was made of each for a thorough comprehension of the lesions.

_Materials_