Part 5

Before referring to the physical signs it might be well to describe the condition and general appearance of the patient when the lungs became involved. The patient who had been progressing with an apparently simple influenza, with no chest signs except those of bronchitis or tracheitis, occasionally slightly cyanotic, became more cyanotic, the elevation of temperature continued longer than three to seven days, or if it came to the normal began to rise again, his respirations gradually increased and the pain in the chest became well localized. One could safely assume that the patient had developed a lesion in the chest. This could not always be localized during the first few hours or on the first day. The evidence of increased bronchial disturbance was frequently recognized, and later impairment of resonance and diminished breath sounds associated with “a few crackles” were noted. This, so far as we can tell, may have been the only evidence of the stage of œdema or “wet lung.” After this, as the disease advanced, definitely increased vocal fremitus and rather definite tubular breathing with greater impairment of resonance were noticed. These signs were usually observed first at the apex of the left lower lobe, and from here they extended forward along the inter-lobar sulcus, or downward along the spinal column. If the lesion was noticed first on the left side, in a day or two it was found more or less definitely in the right lower lobe also. It seemed to occur more frequently first in the body of the right lobe, instead of in the apex of the lobe as on the left side. In both lobes it might spread to contiguous areas and form a massive consolidation, or it might be found in small separate areas, some of which would clear up in a day, while others would persist.

The expectoration was frothy, containing either blood or masses of yellowish, greenish purulent material floating in a watery sanguiolent or clear fluid, or enmeshed in frothy mucus. The amount of expectoration in some cases was enormous, but as a rule it was scanty. It was thick and ropy at times and distinctly annoying to the patient.

At this stage the physical signs were very much in accord with those of broncho-pneumonia. In a few hours sometimes, or in a day, the small areas of consolidation became confluent and massive consolidation was formed. It appeared as though the whole lobe would in time become solid, as in a true lobar pneumonia. Or the original areas may apparently have cleared and other areas involved, became the centers of massive consolidations. In many cases both lower lobes were thus similarly affected, and one had the physical signs of a double lobar pneumonia. However, nearly always a small angle of the lobe remained clear, thus differing from the entire lobe involvement characteristic of a true croupous pneumonia. Other signs, such as the absence of vesicular breathing and presence of the crepitant râle, moist râles of all sizes to very coarse râles, could be noted. As in certain stages of a complete consolidation, the lung might be dry; no râles present, but definite tubular breathing present. This in a day or two, or after a longer time, might give the signs of resolution. The stage of resolution, however, was almost invariably prolonged, sometimes extending over weeks. With these variable lung signs were often mingled the signs of a fibrinous or serofibrinous pleurisy, which occasionally but remarkably infrequently went on to effusion or empyæma.

As stated above, the demonstrable pathology was in the lower lobe, and more frequently in the left than in the right, only occasionally in the middle lobe, and never, we might say, in the upper lobes. The very earliest definite signs were found at the apex of the left lower lobe.

This observation seems to be entirely contradictory to that of the pathologist, who found in 65 per cent. of all cases coming to autopsy a lesion in all the lobes of the lungs (Klotz). The only explanation we can give which seems at all satisfactory to us is that the pathology in the upper and middle lobes must not have been sufficient, or must have been of such a nature that it did not yield the physical signs, i. e., definite impaired percussion resonance, increased vocal fremitus and tubular breathing, with varying shades of moist râles—signs upon which we insisted before we were willing to state definitely that there is a demonstrable pneumonia present.

In this description it has been attempted to follow the order of invasion in a lung which seemed to go through the entire course of the disease. There were, necessarily, all degrees of the process, some cases showing few signs and yet being remarkably ill, and others all of the signs with very little other evidence of serious illness.

We were continually impressed with the notion that the pathology in the lung, at least the pathology demonstrable physically, did not tell the whole story of the case, and that the outcome depended as much or possibly more upon a general infection or toxæmia of which the recognized condition in the respiratory system was only a small part. We were particularly impressed with this in the success or failure following the application of any therapeutic measures. It was quite a common remark, therefore, in the wards of the hospital among those associated in the work that “the patient died too quickly to permit of the succession of the various stages of pneumonia”; or, in the autopsy room, that if the patient had lived long enough he would have had demonstrable, well-recognized pathology of the lung, instead of the cyanotic, wet, spongy lung which was found.

The temperature course in the pulmonary cases was characterized by its irregularities, and by its being entirely out of harmony with the extent and severity of the lung invasion in so far as it could be interpreted by the physical signs. The temperature as described in a simple influenza might not come to the normal in the time of three to seven days, and might even go higher, with no demonstrable chest signs, but with every other evidence of lung involvement. Later the temperature might come down by lysis, which was the usual way, and the chest signs gradually or suddenly become evident. The temperature might remain normal throughout the rest of the course, and a lobe or even both lower lobes of the lungs be as solid as in a true lobar pneumonia. Occasionally the temperature fell by crisis, but there was no associated change in the physical signs of the chest. In short, the temperature seemed to run a course entirely independent of the physical signs in the chest. In two remarkable cases seen in consultation on two consecutive days the physicians in charge declared that no signs of consolidation could be found, though all other evidences of pneumonia were present. In the 12 hours which had elapsed from the time the last examination was made the temperature fell by crisis. At the consultation, to the surprise of the family physicians, we found both lower lobes consolidated, it having occurred apparently with the crisis. Both patients were healthy-looking, robust, young men, and both recovered with delayed resolution. In the convalescence of such cases, if the patient got up too soon or if any other indiscretion took place, a relighting of the lung occurred. From the above description it can be readily seen that a diagnosis of the conditions in the chest in influenzal pneumonia was frequently impossible, because one had to abandon all his previous ideas of pneumonia, in so far as onset, crisis, blood picture, sputum, temperature, respiratory and circulatory phenomena, physical signs and prognosis were concerned.

Assistance from the laboratory was meager, especially in the early days of the epidemic. This was due largely to the inability to get laboratory workers in sufficient numbers to follow the work through, but more largely to the fact that we were unable to interpret the unusual laboratory results which were available. When we were once fully aware of the difficulties in diagnosis which confronted us, we utilized every practical means at our disposal. Among these was an examination of the chest with the X-ray. On account of lack of facilities and of help, it was impossible to make routine X-ray examinations of the chest in all cases. Besides, it was difficult to interpret the X-ray findings, on account of the unusual character of the lesions. Also, many of the patients were so desperately ill one hesitated to disturb them. We hear that other clinics had similar experiences, and that very little substantial help came from the X-ray, except in cases with complications. Several attempts were made to determine the kind of shadow, if any, the “cyanotic, œdematous, wet” lung would make, but no satisfactory observations have been forthcoming. From our own observations and from the discussions of other observers, it would seem to us that the stereoscopic examination of these chests is the only possible way of getting satisfactory plate readings in these cases where the pathology seems so lawless in its extent and peculiar in its distribution. This method of examination, however, demands facilities convenient at the bedside and perfect co-operation of the patient—difficult conditions to meet under the circumstances. In the acute cases, when the desire to make a diagnosis not only of the presence but of the extent of the disease was keen, X-ray examination was largely impractical. In cases of delayed resolution, or in cases with complications with prolonged convalescence, X-ray examinations were extremely helpful.

_Diagnosis of Influenzal Pneumonia_

In the consideration of any disease the well-trodden path of a painstaking history, a thorough physical examination, and reliable laboratory investigation, together with an intelligent interpretation, will usually lead to a definite diagnosis. In certain diseases, as is well known, the stress must be placed about equally on all of these factors, while in others one or other factor predominates. In influenzal pneumonia, until more is known of the etiology (bacteriology) and of the pathological changes and of the physiological disturbances, the controlling factor in the diagnosis (we feel embarrassed to admit) must be the history. This is true not only of the diagnosis of influenza with or without pulmonary involvement, but is also true of the diagnosis of the various complications, and will be found to be particularly true in the recognition of the bizarre sequelæ, which no doubt in the succeeding months or years will be attributed to or will follow in the train of influenza.

With the knowledge that there is a prevailing epidemic of influenza and that the manifestations are largely in the respiratory tract, any pulmonary disturbance will necessarily make one suspicious of the presence or the oncoming of an influenzal pneumonia in the patient under consideration. The history of the onset, as of simple influenza, is the greatest factor. This with a continued temperature, cough, cyanosis, slow pulse, continued asthenia, or even an unusual leucopenia, may have a greater weight in determining the diagnosis of lung involvement than will the apparently definite or, as it may happen, the confusing chest signs. To differentiate from ordinary bronchitis, broncho-pneumonia and catarrhal pneumonia, one need only refer additionally to the severity and persistency of the disease when it is of the influenzal type, as compared with the mildness of the ordinary type. To differentiate it from croupous pneumonia, one need only compare the confusing symptom picture of the influenzal pneumonia with the definite, clear picture of ordinary pneumonia; or the confusing kaleidoscopic chest signs of the one with the definite, clear-cut signs of the other. The laboratory thus far has been the smallest factor in making the diagnosis, in that sputum examinations, blood examinations, blood cultures and urine examinations are mostly negative in their results, or at least the findings are not specific. We do not, however, mean to indicate that these tests are not of the greatest value. The leucopenia is the one outstanding feature which seems to have separated this infection from other acute lung infections, excepting miliary tuberculosis. The differentiation of influenzal pneumonia from an acute tuberculous process in the lung may be difficult, especially if there is no reliable history available. However, the fact that pulmonary tuberculosis usually begins at the apices of the lungs and influenzal pneumonia at the bases or at the apices of the lower lobes is quite helpful. Of course, the examination of the sputum for tubercle bacilli will be a deciding factor.

The differentiation between influenzal pneumonia and diseases of the pleura is one which practically rarely needs to be made, for there seem to be very few cases of influenzal infection of the lungs in which the pleura is not also involved to a greater or lesser extent.

_Complications_

In considering the complications of influenza one again comes up squarely against the question: What is influenza and what is the specific micro-organism responsible for it? If the Pfeiffer bacillus is the specific cause, what pathology can be attributed to it? It has been an almost universal observation that the lesions in the lungs and pleura which characterized the group of cases with lung involvement rarely yielded a pure culture of the Pfeiffer bacillus, and that secondly in a large percentage of cases the Pfeiffer bacillus apparently was absent, and that other micro-organisms, such as the pneumococcus, streptococcus, micro-organisms commonly found in the pneumonic processes, were present and predominated. The question arises, therefore, may not all the influenzas with lung involvement be _complications_ of influenza? It is our feeling that Pfeiffer bacillus is present throughout the respiratory tract in all cases, and while it may of itself produce a lesion like a broncho-pneumonia or a lobar pneumonia, it chiefly prepares the soil for other germs which may happen to be present, and which are more commonly found in the pneumonias. We, therefore, look upon the lesion commonly found in the lung as being a part of rather than a complication of influenza, and look upon lesions elsewhere, due to the influenzal or other micro-organisms, as a definite complication.

There is no doubt that the most frequent complication of influenza, especially in the present epidemic, is in connection with the pleural membranes. When one recalls that pneumonia rarely occurs without there being also a pleuritis, and also when one recognizes that in an influenzal infection of the lungs the specific micro-organism, together with any other micro-organism which may happen to be present, seems to run riot, apparently abandoning its usual mode of invasion, it can be readily understood why this complication is so frequent and so varied. The pleurisy was usually of the fibrinous type, and rarely was accompanied with demonstrable fluid. Of the 153 soldiers in only 3 was fluid detected in the chest, and of the 394 civilians only 10 showed fluid. In many more cases fluid was suspected, but X-ray examinations and free needling of the chest showed that we had misinterpreted the physical signs.

After our experience in the epidemic of pneumonia in the spring of 1918, when the disease was also so prevalent in the cantonments, we of course expected to see many cases of empyæma and lung abscess in the present epidemic. In this we were agreeably disappointed. Only one case of empyæma and only one case with abscess of the lung were found up to the time of collecting our data and the compiling of our statistics. Both of these were among the civilians. From our experience since the compiling of our statistics, we are inclined to believe that this low incidence of empyæma may not altogether represent the real state of affairs, as we have since received in the hospital several cases of empyæma, as well as of abscess of the lung, which seemed to have followed an influenzal infection which had occurred three or four months previously. One of these cases was a particularly remarkable one, in that the patient had already been admitted to the hospital twice since his initial attack of influenza in October for suspected pleurisy with effusion. We were unable to find any fluid with the needle, though we felt certain of having demonstrated it a number of times physically and with the X-ray. About eight weeks after the second admission, however, pus was found after several needlings in the left chest, axillary space, apparently along the inter-lobar sulcus. This case was a good example of many we have seen in which a pneumonia, or possibly, as we see it now, a pleurisy, or even a localized empyæma, seemed to confine itself about the sulcus or fissure between the upper and lower lobes of the lung. Frequently the process began posteriorly, apparently at the apex of the lower lobe, and traveled forward and downward across the axillary space until it appeared in the anterior part of the chest. In most cases we interpreted our signs as those of a consolidated lung, and scarcely knew whether the consolidation was in the upper part of the lower lobe or in the lower part of the upper, or in both. In some cases we suspected a localized empyæma or an abscess in the sulcus, but in none did we find pus after exploring with the needle until this recent case occurred. The passage of the needle in this case, which was done several times before pus was found, always gave the impression that it was going through dense fibrous tissue for some distance before the abscess was finally found. From this experience, and from the extensive and irregular invasion of the pleura which we have seen demonstrated at autopsies, there can be no doubt that the clinical history of the complications of influenza in this epidemic is not a closed chapter.

In six patients there was a purulent inflammation of the pharynx, larynx and trachea. It was extensive and produced profound general symptoms, dyspnœa and profuse purulent expectoration. The lungs were clear, but the patient seemed for a time in danger of death. The condition was considered a grave complication. There was only one case of acute sinusitis, one case of antrum disease, and only four cases of middle ear infection were recognized. This is in marked contrast to other epidemics which have occurred to our knowledge in the past fifteen years or more, and which have been spoken of as influenza or “grippe.” Disease of the tonsils, middle ear disease, mastoid disease and sinus disease occurred with great frequency in those sporadic epidemics. This again seems to show that the deep respiratory tract was more generally and more severely affected in this epidemic than the upper respiratory tract.

With the exception of the pleura, the serous membranes were remarkably free from infection. Only one case of acute endocarditis, three cases of meningitis (all pneumococcic), none of pericarditis, peritonitis or arthritis were recognized among the 547 cases of influenza.

The kidneys did not seem to be involved in the infection. Albumen was present in the urine, as might be expected in febrile conditions, but no evidence of acute clinical nephritis, such as suppression of urine, general œdema or uræmia, was recognized. The condition of the urine in this epidemic will be described more in detail in another paper of this series.

A peculiar pathological process in the muscles was brought to our attention by Dr. Klotz, who demonstrated a myositis or hyaline degeneration of the lower end of the recti abdominalis. This lesion is carefully described in the pathological section. After our attention had been called to this lesion we recognized several cases clinically having the same condition. One was in the right sterno-cleido-mastoid muscle and another was in the left ilio-psoas muscle. This last patient while he was convalescing developed a severe pain in the left hip, extending upward into the lumbar region and downward into the thigh. His decubitus was like that of one suffering with psoas abscess. Every test available was made to confirm this diagnosis, but all the findings were negative. The patient rested in the hospital, in bed, for some time, gradually improved, and eventually made a complete recovery.

In several cases we also detected an osteitis, especially of the bodies of the vertebræ. One was of the cervical vertebræ and the other of the dorsal. The first died after intense suffering. An autopsy was not obtained. The other had a plaster cast applied as in Pott’s disease, and improved sufficiently to leave the hospital in comfort. One hesitates under the circumstances to attribute these bone lesions definitely to the same infecting micro-organism which was responsible for the epidemic of influenza, as it might easily have happened that a coincident quiescent tuberculous lesion was present and relighted during the epidemic. However, in one case from the service of Dr. J. O. Wallace the possibility of the bone lesions being due to the Pfeiffer bacillus was demonstrated. This was a child of 16 months with an epiphysitis of the upper end of the tibia. The inflamed area was incised and pus was found. A smear at the time showed the B. influenzæ, which was grown in pure culture.

A most interesting complication noted in a few of our cases was a transient glycosuria. The first case brought to our attention was a middle-aged female, who complained of failure of vision. Upon making an ophthalmoscopic examination a papillitis of a mild type was noticed. This led to a careful study of the urine, and sugar was found in a small amount for a short period of three days, although the glycosuria readily disappeared by cutting down the carbohydrate intake, the vision came back to normal more slowly. In fact, it was almost one month before the symptoms and signs of the retinal change had entirely disappeared. It is interesting in this connection to recall similar cases referred to in Allbutt’s System of Medicine, vol. vi, on influenza, following the epidemic of 1890 in England. Other transient glycosurias showed no visual changes. We do not consider these to be true cases of diabetes mellitus. In all a transient hyperglycæmia was also noted.

_Pregnancy_

A condition which can scarcely be considered as a complication of influenza, but which, however, was a large factor in increasing the mortality among women, was pregnancy. Among the cases included in this study were five pregnant women, who came to the hospital and were referred to the medical service. As soon as a complication relative to the existing pregnancy arose they were referred to the Obstetrical Department. On account of the great amount of work in caring for the influenzal patients, and on account of the scarcity of physicians and nurses, we were unable to follow these cases closely enough to give any such definite data as we wish. Three miscarried or went into premature labor. Happily only one of them died. The two which did not miscarry recovered and left the hospital well.