Part 7

It appears to us not at all improbable that the so-called psychoneuroses of which fatigue, nervousness, irritability and tachycardia play such an important part might also be explained in the same way. These constitute a group of sequelæ which were frequently recognized after previous epidemics, and which are again coming to the foreground.

We are of the opinion, on account of the apparent absence of any specific pathology of the gastro-intestinal tract and its appendages during the attack of influenza, that the sequelæ referred to the digestive system are largely due to exacerbations of previous physiological disturbances or pathological processes. The patient with a previous peptic ulcer has a recurrence of his ulcer. The patient with an infection of the biliary tract has an acute exacerbation, or may have an attack of biliary colic. In fact, there seem to have been many more cases of this kind since the epidemic than before, and most of the patients date the time of the onset from a period soon after recovering from influenza.

Very few, if any, patients in our experience have exhibited sequelæ due to disease of the cardio-vascular or genito-urinary systems. It may be that these will appear later when the more remote effects of an acute infection are recorded.

A very commonplace sequel, but of more or less interest, is the tendency to furunculosis. Our attention was particularly called to the associated hyperglycæmia. The blood sugar readings varied from 0.2 to 0.41. There was no glycosuria, acetone or diacetic acid. We have no explanation to offer for this, although one might dilate readily on many attractive theories. The hyperglycæmia, one may add, was readily reduced by a lowered carbohydrate intake, which also had a curative action on the furunculosis.

Finally we would mention the peculiar epidemic which has been observed apparently over the world, encephalitis lethargica. We do not for a moment put ourselves on record as regarding this disease as a post-influenzal affair, but no one will deny that it has a peculiar time relation to the epidemic; and further, that its distribution is apparently identical. Its bacteriology seems to be unknown. Its local pathology in the mid-brain is not peculiar or at variance with encephalitis produced by known organisms. We have seen five cases; three of whom had had undoubted influenza, while the other two were entirely free from even the slightest suggestion of any type of illness previous to the attack. All of these cases recovered. It has been stated that following the 1890 epidemic a clinical condition was observed in Europe which bears a close resemblance to what has been termed at the present time encephalitis lethargica.

Prognosis and Mortality of Influenza

In giving a prognosis of influenza one has to take into consideration the peculiar manifestations of the disease, especially the possible and sudden changes which are liable to take place in the lungs. The points which lead one to feel that the outlook is grave occur in about the following order, which is also about the order of the severity of the symptoms. First, cyanosis. This usually appeared quite early and was considered a forerunner of definite lung infection. It may have been a symptom only of the “wet lung,” to which reference has been made, but it was usually followed with definitely recognized pathology in the chest, and it immediately made the outlook unfavorable. Second, continuation of elevated temperature. If the temperature fell to normal in three or four days, the outlook was, of course, good; but if it went up again, or if the temperature did not fall in that time, the chances were that there was a lung involvement, even though the chest signs were negative or only those of an acute bronchitis. Strange to say, however, when definite chest signs were once recognized, the height of the temperature or the continuation of fever was not so important a prognostic factor. Third, increase in pulse rate. The pulse, as was noted before, was unusually slow, even though the patient seemed desperately ill; when, however, it began to increase in rate the condition was usually very grave. Fourth, the extent of lung involvement. This was of very little prognostic value. Both lower lobes might be solid, and yet if there was no cyanosis and the pulse and respirations were satisfactory, the outlook was rather good. On the other hand, there might be the slightest involvement of the lung, and if the pulse were rapid and cyanosis present the outlook was grave. Fifth, depression and stupor, or loss of so-called “morale.” If the patient remained clear in his mind, bright and hopeful, no difference how extensive the involvement or how grave the symptoms, the prospect of recovery was better. This is, of course, not peculiar to influenza, but it seemed particularly striking during the epidemic. Sixth, a gradually rising rate in respiration, which often was not more than two per minute per day, if progressive, even in the absence of other untoward signs, conveyed a serious prognosis.

Our mortality among the civilians in comparison with the soldiers was exceedingly high. The first cases seen by us were among the soldier patients sent to the hospital. These were as fine a lot of healthy young men as one can well imagine. They came to the hospital comparatively early in the infection. After the first week it appeared as though our experience would be entirely different from those in other localities, for we had very few deaths. In another week our mortality began to rise, but never as high as among the civilians, as will be seen by the following figures.

Of the 153 soldiers 87 were without lung involvement, and of these none died; 66 had lung involvement, and of these 16 died. Mortality among the 153 was 10 per cent. Of the 394 civilians 157 were without lung involvement, and of these 1 died; 237 had lung involvement, or some other complication, and of these 93 died. Mortality among the 394 was 23.6 per cent.

It will be seen that the mortality in the civilians was more than twice as high as in the soldiers. It has already been mentioned that the soldiers were ordered to the hospital promptly. The civilian patients, on the other hand, were later in coming to the hospital, some of them appearing when they had already developed serious complications. Another factor in determining the mortality were the ages of the patients. The soldiers ranged from 18 to 34 years, with an average of 20 years. The civilians ranged from 6 months to 73 years, with an average of 30 years. Generally speaking, the greater the age the higher was the mortality.

A third factor which should be considered in determining the actual mortality is the result of later complications and sequelæ. The figures as given are those of 547 patients, 110 of whom had died in the Mercy Hospital and 437 of whom had been discharged therefrom between September 22 and November 30, 1918, the length of the quarantine. Those who were discharged had been up and about for a week or 10 days before leaving the hospital. From our experience with post-influenzal patients admitted to the Mercy Hospital since November 30, we are of the opinion that some of the patients discharged before November 30 as recovered may have later developed sequelæ which might have proved fatal. No follow-up system has been pursued as yet which enables us to speak definitely and statistically of the present condition of those discharged.

This compilation does not readily lend itself to drawing any more specific conclusions, but we cannot desist from expressing our opinion that in the clinical study of this recent epidemic we find very little that may not have been observed by clinicians in previous epidemics.

THE URINE AND BLOOD IN EPIDEMIC INFLUENZA

By PETER I. ZEEDICK, M. D.

Epidemic influenza, unlike other acute infectious processes as diphtheria and scarlet fever, seemingly attacks the kidney in a rather mild manner. This statement refers only to the uncomplicated cases, as other bacterial or toxic agents do play a part in the nephritides occurring so often with the pneumonias or other complications following influenza. It is, however, true that in many simple epidemic cases there is evidence of a transient mild nephritis, or possibly, more correctly stated, a nephrosis. Some writers observed albuminuria in 80 per cent. of the cases, while the incidence in other reports varies from 4 to 66 per cent. It is not always stated with reference to these figures that the patients clinically were free from the common complication—pneumonia. The findings of various observers differ greatly, but they all agree that acute nephritis as a serious sequel is somewhat rare.

In the literature of the past epidemics general acknowledgment has been accorded to the presence of albumin in the urine during the acute stage of the disease. Many times this has received no further notice or comment than “febrile albuminuria.” The association of occasional hyaline and granular casts has also been mentioned. One is impressed with the fact that the older observers laid but little emphasis on the urinary findings. It also seems to be true that nephritis as a clinical entity is not prone to follow the epidemics. In general, our conclusions from the last epidemic are about the same.

The data for this paper was obtained from examination of 994 specimens of urine from 750 patients; of this number 517 specimens were examined at the Magee Hospital, where members of the S. A. T. C., all young men, were treated, and 447 specimens from the Mercy Hospital, where, in addition to the S. A. T. C., we had men, women and children. On account of the large amount of material and work on hand, as a rule only one specimen of urine was examined from each patient, but where complications were suspected repeated daily examinations were made. We have grouped our results in tables, so that the various points may be more readily followed.

Table I shows the urinary findings of uncomplicated influenza cases admitted to the wards of the Mercy Hospital. None of these cases developed pneumonia and, after running the usual course, recovered. We would call attention to the fact that 25 per cent. showed albuminuria. The amount of albumin was never excessive, and very often was little more than a faint trace. On the other hand, we have had a few patients where a previous kidney lesion was known to be present, and naturally in these cases a heavy cloud of albumin was met with. The albuminuria was almost always a transient affair, lasting only during the acute part of the illness, and would rightly come under the class of febrile albuminuria. We regard it as being more the evidence of nephrosis than a nephritis. As a rule, the time for the appearance of albumin was after the fever had been present for at least two or three days. One rarely met with it in the short attacks of influenza where the temperature came to normal in less than 72 hours. A certain time factor appeared to be necessary in order for the nephrosis to develop. Another point of interest is the presence of red and white blood cells seen relatively frequently during the early days of the illness. One wonders if this finding is analogous to the bleeding from the nose and lung so often met with at the onset of the disease. The red blood cells were seen microscopically, and only very rarely did we encounter a smoky urine.

TABLE I

URINE ANALYSIS IN CASES OF UNCOMPLICATED INFLUENZA AT THE MERCY HOSPITAL

───────┬─────────┬───────────────────────────────┬──────┬──────┬────── Day of │Total No.│ │ │ │ Disease│ of │ SPECIFIC GRAVITY │ Alb. │R.B.C.│Casts │Specimens│ │ │ │ ───────┼─────────┼───────┬───────┬───────┬───────┼──────┼──────┼────── │ │1001–10│1011–20│1021–30│1031–40│ │ │ ───────┼─────────┼───────┼───────┼───────┼───────┼──────┼──────┼────── 2│ 118│ 8│ 31│ 61│ 18│ 29│ 17│ 8 3│ 97│ 8│ 15│ 62│ 12│ 23│ 10│ 11 4│ 51│ 9│ 22│ 17│ 3│ 11│ 7│ 5│ 24│ 4│ 2│ 14│ 4│ 5│ 3│ 4 6│ 11│ │ │ 8│ 3│ 4│ │ 7│ 25│ │ 10│ 14│ 1│ 8│ │ 8│ 12│ │ 2│ 8│ 2│ 6│ │ 3 9│ 4│ │ 2│ 1│ 1│ 2│ │ 18│ 2│ │ 1│ 1│ │ │ │ ───────┼─────────┼───────┼───────┼───────┼───────┼──────┼──────┼────── Totals │ 344│ 29│ 95│ 186│ 44│ 88│ 37│ 26 ───────┴─────────┴───────┴───────┴───────┴───────┴──────┴──────┴──────

TABLE II

URINE ANALYSIS IN CASES OF UNCOMPLICATED INFLUENZA AT THE MAGEE HOSPITAL

───────┬─────────┬───────────────────────────────┬──────┬──────┬────── Day of │Total No.│ │ │ │ Disease│ of │ SPECIFIC GRAVITY │ Alb. │R.B.C.│Casts │Specimens│ │ │ │ ───────┼─────────┼───────┬───────┬───────┬───────┼──────┼──────┼────── │ │1001–10│1011–20│1021–30│1031–40│ │ │ ───────┼─────────┼───────┼───────┼───────┼───────┼──────┼──────┼────── 1│ 101│ 6│ 22│ 49│ 24│ 5│ │ 3 2│ 127│ 1│ 17│ 75│ 34│ 13│ │ 3 3│ 82│ 3│ 13│ 55│ 11│ 13│ 1│ 4 4│ 36│ 1│ 14│ 18│ 3│ 4│ │ 2 5│ 40│ 2│ 9│ 24│ 5│ 6│ 1│ 2 6│ 23│ 1│ 5│ 15│ 2│ 7│ 1│ 3 7│ 5│ │ 1│ 4│ │ 3│ │ 2 8│ 5│ 1│ │ 4│ │ │ │ 9│ 2│ 1│ │ 1│ │ │ │ 10│ 10│ 1│ 3│ 5│ 1│ 2│ │ 1 11│ 3│ │ │ 3│ │ 2│ │ 1 12│ 3│ │ 1│ 2│ │ 2│ 1│ 13│ 1│ │ 1│ 3│ │ │ │ 14│ 1│ │ │ 1│ │ │ │ 15│ 5│ │ 1│ 4│ │ │ │ ───────┼─────────┼───────┼───────┼───────┼───────┼──────┼──────┼────── Totals │ 447│ 17│ 87│ 263│ 80│ 57│ 4│ 21 ───────┴─────────┴───────┴───────┴───────┴───────┴──────┴──────┴──────

The results shown in Table II illustrate the urinary findings at the Magee Hospital, and, as in the previous table, include cases of influenza which did not develop pneumonia. The specimens examined were obtained from young, healthy men, between the ages of 20 and 32, and showed albumin in 13 per cent. of the cases. This age factor probably accounts for the lower incidence of albuminuria for this group.

TABLE III

URINE ANALYSIS IN CASES OF PNEUMONIA (INFLUENZAL) AT THE MERCY HOSPITAL

───────┬─────────┬───────────────────────────────┬──────┬──────┬────── Day of │Total No.│ │ │ │ Disease│ of │ SPECIFIC GRAVITY │ Alb. │R.B.C.│Casts │Specimens│ │ │ │ ───────┼─────────┼───────┬───────┬───────┬───────┼──────┼──────┼────── │ │1001–10│1011–20│1021–30│1031–40│ │ │ ───────┼─────────┼───────┼───────┼───────┼───────┼──────┼──────┼────── 1│ 47│ 4│ 14│ 25│ 2│ 36│ 7│ 6 2│ 22│ 1│ 8│ 9│ 4│ 19│ 1│ 4 3│ 9│ 2│ 3│ 3│ 1│ 7│ 1│ 4│ 6│ 1│ 3│ 2│ │ 4│ 1│ 5│ 6│ 1│ │ 5│ │ 5│ │ 1 6│ 16│ 2│ 7│ 7│ │ 13│ 2│ 7 7│ 9│ │ 5│ 3│ 1│ 8│ │ 8│ 3│ │ 1│ 2│ │ 3│ │ 9│ 3│ │ 2│ │ │ 2│ │ 10│ 1│ │ │ │ │ 1│ │ 11│ │ │ │ │ │ │ │ 12│ 3│ │ 2│ 1│ │ 2│ │ 13│ 4│ │ 1│ 3│ │ 3│ │ 1 14│ 2│ │ │ 2│ │ 2│ │ 15│ │ │ │ │ │ │ │ 16│ │ │ │ │ │ │ │ 17│ │ │ │ │ │ │ │ 18│ 1│ │ │ 1│ │ 1│ │ 19│ │ │ │ │ │ │ │ 20│ 1│ │ 1│ │ │ │ │ ───────┼─────────┼───────┼───────┼───────┼───────┼──────┼──────┼────── Totals │ 133│ 11│ 47│ 63│ 8│ 106│ 13│ 19 ───────┴─────────┴───────┴───────┴───────┴───────┴──────┴──────┴──────