In former epidemics, as also in this one, marked prostration was recognized as coming at the height of the disease and remaining persistently during convalescence. But it does not seem to be recorded as among the first symptoms.
Influenza with Lung Involvement
Of the group with lung involvement much may be written from a clinical standpoint, and much confusion may be brought about. Especially is this so if one has no definite idea of the pathology present, or if one enters into a discussion of the character of the infection—a point upon which there is as yet no unanimity of opinion. From the many reports which have been put forth from the base hospitals of the various cantonments, and also from the reports coming from civilian practice, it is evident that scarcely any two groups of laboratory men or any two individuals of those separate groups have the same idea as to the bacteriology and the pathology peculiar to this epidemic.
As long as there is this confusion and element of doubt in the minds of those to whom we are accustomed to look, the clinician must necessarily speak with considerable hesitancy, especially when he attempts to interpret the physical signs observed. In our own group the observations of Klotz, Guthrie, Holman and others have given us an interpretation of our clinical findings which, at present at least, is more or less satisfactory. We shall definitely keep in mind their observations and conclusions as we go on with the description of the physical signs of the chest in cases having lung involvement.
In the description of this group it will readily be seen that the lower respiratory tract stood the brunt of the infection. Of the 153 soldiers under our care, 60, or about 40 per cent., were recognized as having pneumonia. Of these, 34 had undoubted demonstrable signs, while 26 were questionable, and yet from the temperature and other symptoms we concluded there was a pneumonia. Of the 394 civilians, 189, or about 50 per cent., had pneumonia. Of this group there were again some 28 or 30 in which the diagnosis was doubtful, according to the ordinary way of making a diagnosis, but we felt sure from the temperature course that more than a simple influenza was present. In the description of the physical findings of the chest in these influenzas with lung involvement it will be readily seen why the diagnosis must sometimes be in doubt.
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.
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