| Day of Disease on Which Death Occurred | Number of Cases |
|---|---|
| Third | 1 |
| Fourth | 3 |
| Fifth | 4 |
| Sixth | 4 |
| Seventh | 4 |
| Eighth | 5 |
| Ninth | 3 |
| Tenth | 4 |
| Eleventh | 3 |
| Thirteenth | 1 |
| Fourteenth | 1 |
| Twentieth | 1 |
| Twenty-third | 1 |
The time as indicated in the above table has no relation to the length of time that the patients were ill of pneumonia, but refer to the period of illness from the beginning of the influenza. The duration of the pneumonia is indicated in another table.
Of the 35 fatal cases 32 came to autopsy. Facilities were available to do the work very satisfactorily, in that the hospital was well provided with a modern post-mortem room and its accessories. The notes on the autopsies were taken immediately and fully, and the materials for subsequent study were collected in different types of preserving fluid. Portions of tissue were collected from all of the organs for microscopical study, while fluids from the chest, lungs, bronchi and heart were obtained for bacteriological investigations and for some chemical analyses.
Added to the above material we also had the opportunity of reviewing and studying the lesions of 18 autopsies performed by Dr. J. W. McMeans. These cases were very similar to our own series, in that they were cases of epidemic influenza amongst soldiers who were being cared for at the St. Francis Hospital. The disease processes were quite alike in the two series, and the analyses made by Dr. McMeans are comparable in our own and serve as a means of checking our results obtained in another institution. The similarity of the lesions in the lungs and other organs serve to indicate that what is reported in this paper is an index of the nature of the lesions of epidemic influenza as it occurred in the Pittsburgh district. In a few instances the autopsies performed by Dr. McMeans revealed more advanced pulmonary lesions with abscess and gangrene than were noted in the cases autopsied at the Military Hospital. The process, however, in the two series of autopsies was identical.
General External Features
There were no external characteristics of the bodies which were autopsied by us which were constant. Some features were more commonly present than others. Of these the cyanosis of the face, head, neck and shoulders, and in a few instances of the upper extremities, attracted our attention more than any other. This cyanosis was present in over one-half of the number of cases, and it was confined almost always to the upper part of the body. The face, ears and neck were always more affected than other parts. This cyanosis bore no relation to the length of time after death when the body was viewed, as we found that when it was present during life it maintained its prominent appearance for a long time after death.
The cyanosis differed from the bright hue or flush as it is at times observed in ordinary pneumonia, the color in these instances being of a dark purple, or better a purplish blue. The lips and ears showed the most intense color. The cyanosis was not associated with any evidence of œdema. The capillaries of the tissues were filled with blood which was of a very dark character. Cyanosis could also be seen in the finger tips about the nails. This was more marked in the upper extremities than in the lower. The skin of the body rarely showed any cyanosis, these tissues being quite pale, or at times showing a slightly yellowish tinge. In one instance the cyanosis of the head and neck was accompanied by a slight purplish rash upon the upper portion of the chest. This rash was of a petechial kind, there being slight hemorrhage into the tissues. The lesion, however, was not of the blotchy purpuric type which has been observed by others during this and past epidemics (Cole). This single case is the only one where we had evidence of superficial hemorrhages into the skin.
TABLE III
| Cyanosis | No Cyanosis | ||
| No. | Degree | Distribution | |
| 741 | + | Chest and upper extremities | 747 |
| 743 | + + | Face, neck and ears | 748 |
| 744 | + + + | Head and neck (upper portion of chest and thighs mottled and purple) | 749 |
| 745 | + + | Head and neck and upper extremities | 751 |
| 746 | + + | Ears, neck and shoulders | 752 |
| 750 | + + | Face, ears and neck | 764 |
| 756 | + + | Neck, jaw, shoulders and upper extremities | 765 |
| 757 | + | Face, neck, shoulders, arms and chest | 778 |
| 758 | + + + | Face, ears, neck and upper chest | 782 |
| 761 | + | Face, ears, neck and upper chest | 784 |
| 762 | + | Ears, neck and chest | 786 |
| 763 | + | Head and neck | 793 |
| 767 | + | Face, ears and neck | |
| 773 | + + | Neck, ears and cheeks, extending moderately to upper chest. Hemorrhage into conjunctiva | |
| 781 | + + | Eyes, lips, ears and neck | |
| 783 | + + | Face, lips, neck and fingers | |
| 787 | + + + | Ears, neck and shoulders | |
| 791 | + + | Ears, neck and upper chest | |
| 792 | + + | Ears and back of neck | |
| 19 | + Blotchy or slight 6 | 12 or | |
| or | ++ Moderate 10 | 38.6% | |
| 61.4% | +++ Well marked 3 | ||
| 770 | Fine petechial rash over upper chest. |
Occasionally we met with small hemorrhages lying in the upper layers of the subcutaneous tissue. These lesions were small and could not be seen from the external surface. Nevertheless, some of them seemed to have occurred in direct contact with the deep cutis and surrounded portions of the deep skin appendages. From an examination of our cases there was no reason at the time of autopsy to lay any particular stress upon the occurrence of these hemorrhages. Subsequently, it has come to mind, and since learning of the unusual frequency of boils and deep pustules making their appearance as post-influenzal sequelæ, that these minute lesions may have a bearing upon the localization of infection in the skin tissues. We must appreciate, of course, that other factors of a constitutional nature probably render the individual more susceptible to the invasion of the staphylococcus, and that such factors are all-important in allowing this organism to gain a foothold. Whether the decreased sugar-tolerance with hyperglycemia, which has been observed in the late stages of influenza, bears a relation to the increased susceptibility, as appears to be the case in diabetes mellitus, is an interesting point for further investigation. Other constitutional states are also undoubtedly involved in the increased susceptibility to the infection which the patient suffers. Elsewhere (Dr. Holman) it is shown that the natural complement content is considerably depressed during the height of the influenza. With such factors present and with the available infecting micro-organisms, it is possible that the minute deep skin hemorrhages bear a relation to the immediate localization of the infection.