Clinical Manifestations of 1918 Influenza
January 7th, 2009as Commented Upon in Various Navy Reports
Headache.--Reports generally agree that headache was one of the most constant symptoms in the early stages of influenza. It occurred as the most prominent symptom in from 75 to 80 per cent of 900 cases of influenza analyzed at the United States Naval Hospital, Philadelphia, Pa., and as the chief complaint in from 50 to 30 per cent of the cases according to whether they were admitted to hospital within the first 24 hours of the disease or not until after 72 hours.
Headache was usually frontal. In many reports it was designated as "post-orbital." The eye balls were frequently painful and tender on pressure. Undoubtedly due to the toxemia in some cases, headache was commonly caused by nasal congestion and rhinitis with blocking of the frontal sinuses.
Headache late in the disease was reported as due to a variety of lesions; inflammation of the frontal sinuses, less commonly other accessory sinuses, neuritis, meningitis, embolism, intracranial congestion and abscess.
Prostration.--Prostration of some degree almost from the moment of the sudden onset of influenza was rarely absent. In cases of ordinary severity the initial weakness was almost always out of proportion to the fever and to the pulse and physical findings in comparison with other acute infectious diseases. Even in very mild cases there was often great weakness which persisted throughout the convalescent period and fatigue was often readily induced long after the patient had returned to duty. Instances were very common where unusually strong, fully developed men perfectly well in the afternoon were so weak the following morning upon admission to hospital with influenza that they could scarcely sit up in chairs.
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Many patients became ill on the street while on liberty and had not sufficient strength to return to ship or station.
Prostration was commonly attributed to intense early toxemia which occurred suddenly and in complicated cases developed into a profound adynamic state in which myocarditis and toxic neuritis played a part.
Vertigo.--this was an unpleasant symptom frequently present even in mild cases. While brought on by slight exertion it also occurred frequently when the patient was lying quietly in bed.
Chills.--An initial chill was of very frequent occurrence. A definite chill or chilliness occurred in about 50 per cent of the cases. Chilly sensations commonly recurred during the first 24 hours of the disease and not infrequently chilliness recurred at irregular intervals up to 72 hours.
Muscular pains.--Reports from all ships and stations showed uniform agreement in making mention of the prominence of backache and pains of varying severity in other muscle groups and in the joints. A common description was, "The patient feels as though he had been beaten all over with a club." In the Philadelphia series, general muscular pains were noted as a prominent symptom in from 54 to 63 per cent of all cases admitted to hospital.
Coryza.--A "cold in the head" with sneezing and nasal discharge occurred in the early stages of the disease in perhaps half the cases of influenza. In the Philadelphia series this symptom was noted in 20 per cent of the cases admitted to hospital.
Conjunctivitis.--Some degree of congestion of the conjunctivae accompanied coryza. Congestion of the eyes was noted in from 25 to 30 per cent of the 900 hospital cases carefully studied in Philadelphia. Infrequently conjunctivitis of marked degree was noted and corneal ulcers occurred in several instances in a series of 2,924 cases of influenza studied at the United States Naval Hospital, Great Lakes, Ill.
Nausea and vomiting.--The so-called intestinal form of influenza was not common during this pandemic. Nausea occurred in from 10 to 20 per cent of the cases studied at the United States Naval Hospital, Philadelphia, and vomiting occurred in from 5 to 15 per cent. Nausea and vomiting were more common in cases admitted to hospital late in the disease.
In a few cases, perhaps a dozen, diarrhea was associated with nausea and vomiting. In the majority of these instances there was some abdominal distension and pain with tenderness on palpation, particularly in the right iliac fossa. The pain disappeared quickly, as a rule, but simulated appendicitis while it lasted.
A report from the United States Naval Hospital, Chelsea, Mass., noted that nausea and vomiting occurred in a few cases. At the United States Naval Hospital, Great Lakes, Ill., it was believed that nausea and vomiting in the majority of instances were due to overmedication, as these symptoms were relieved by discontinuing medication.
At the United States Navy Base Hospital No. 5, Brest, France, only one case of what might be termed a definite gastro-intestinal form of grippe with nausea and vomiting and severe diarrhea was noted. In a report from the receiving ship at Norfolk, Va., which included a detailed clinical description of 962 cases of influenza, no mention of
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nausea and vomiting was made, and it is significant that these symptoms were not alluded to in most reports. Diarrhea was not a prominent symptom. In most reports it was not mentioned.
Hematemesis.--Reports indicate that hematemesis occurred very infrequently. It was not mentioned in the report of 2,924 cases at the United States Naval Hospital, Great Lakes, Ill., and in the report from the United States Naval Hospital, Philadelphia, Pa., it is noted that when vomiting occurred the vomitus was usually free from blood. Hematemesis of large amount was not mentioned in any report.
Abdominal distension.--Paralysis of the intestine appears to have preceded death in the majority of fatal cases. Abdominal distension was prone to occur in toxic cases and was difficult to overcome.
Abdominal pain.--Abdominal pain and soreness in the region of the diaphragm were frequently attributed to continued coughing. In some instances degenerative changes in the abdominal muscles were productive of pain. Not infrequently pleuritic pain referred to the region of the gall bladder led to a diagnosis of acute cholecystitis or appendicitis. Occasionally acute cholecystitis did occur.
Hiccough.--Hiccough occurred in approximately 1 per cent of hospital cases. Occasionally it was serious and could not be controlled. Of approximately 3,000 cases of influenza treated in the naval hospital at great Lakes, persistent hiccough occurred in but one instance, the patient dying on the fifth day.
Icterus.--Jaundice occurred infrequently and it is mentioned in only a few reports. It was present, probably, in less than 1 per cent of the cases of influenza. Duodenitis and choledochitis appear to have been rare. Icterus of hematogenous origin occurred occasionally in severe cases and was attributed in a few instances to acute hepatitis. In one case at the United States Naval Hospital, Philadelphia, that of a negro, jaundice was so intense that the sputum was canary yellow in color. Jaundice of some degree was observed in a majority of the fatal cases in the naval hospital at Great Lakes. About 50 per cent of the Philadelphia cases having jaundice terminated fatally.
Nervous system.--In a large majority of influenza cases, even in mild cases, the nervous system was affected to some degree. Insomnia was mentioned in many reports. Somnolence was also frequently noted. Seventy per cent of the hospital cases treated at Great Lakes during the height of the epidemic there exhibited mental apathy. Active delirium occurred in 20 per cent of the cases. Occasionally delirium was active to a maniacal degree. Stupor and lethargy were noted in some instances. Perception was frequently dulled, and often in complicated cases the patient did not realize his serious condition. "Lethargic or mildly stuporous patients with extensive broncho-pneumonia, obviously critically ill and within 24 to 48 hours of death, nevertheless stated that they felt well and requested permission to leave bed and return to duty." On the other hand, marked mental depression was not uncommon in uncomplicated cases of moderate severity and was sometimes associated with a fixed idea that death must follow.
Several observers described cases exhibiting meningeal symptoms; severe headache, stiffness of the neck or retraction of the head and positive Kernig sign with delirium, in which the cerebro-spinal fluid
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was clear. Sometimes lumbar puncture and withdrawal of clear fluid under pressure resulted in prompt alleviation of symptoms.
A mild degree of toxic neuritis of peripheral nerves was not uncommon. Among the sensory phenomena, hyperesthesia, pains in the arms and legs, tingling, itching, heat sensations, and other indications of paresthesia were noted. Sometimes anesthesia followed hyperesthesia. Pain along nerve trunks, notably of the sciatic or median nerve, was complained of in some instances. Various motor nerves were also affected. Some of the fatalities were in part attributed to toxic neuritis of the vagus nerve.
Mental depression not infrequently continued or developed during convalescence from influenza. In the Philadelphia series some post influenzal psychoses were seen. The cases were described as having mild melancholia or suicidal tendencies. One patient had a series of epileptiform convulsions, preceded and followed by melancholia with depressive delusions, from which he ultimately recovered.
Many patients developed neurasthenia during convalescence. Mental depression and loss of interest in the surroundings were noted, and in a number of cases a diagnosis of dementia praecox was made. Recovery usually followed in from 6 to 8 weeks.
Partial paralysis of the palate, ptosis, strabismus, and weakness of various muscles were frequent sequelae even in mild cases of influenza. Impairment of hearing was also observed. Such disabilities usually wore off in the course of a few months.
Temperature, pulse, and respiration.--Many reports agree in the statement that the onset of fever was abrupt. As a rule, the temperature rose rapidly to between 101 and 105 F., and remained high in nearly all cases until a remission occurred on the second, third, or fourth day. In uncomplicated cases the remission usually marked the beginning of convalescence although some cases terminated by lysis, and occasionally a subsequent rise of short duration occurred. A subsequent rise in temperature generally indicated a pulmonary complication, and when the temperature remained high after the sixth day many observers learned by experience to suspect the presence of broncho-pneumonia. In cases of influenzal pneumonia high temperature was the rule--from 104 to 105 F., and frequently higher at certain hours of the day. At the United States Naval Hospital, Puget Sound, Wash., a temperature of 107 F. was observed in one case.
The usual observation was that the pulse was not unduly rapid. Even in pneumonia the rhythm remained regular although it was often momentarily disturbed during a paroxysm of coughing. The pulse was usually soft and the volume large. Frequent mention was made of a poor quality of heart sound at the apex and of muscular impairment. However, cardiac failure per se was not often the immediate cause of death. Many cases were seen in which the apex beat was forcible on palpation and the heart sounds loud and yet the patient was pulseless at the wrist and death was approaching.
Low blood pressure was reported as frequent or constant. The systolic pressure usually ranged from 85 to 110. The diastolic pressure was frequently between 45 and 55. The pulse pressure was often increased.
Many reports indicate that the pulse rate was slow in proportion to the temperature. A pulse of 80 with a temperature of 104° or a
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pulse of 90 with a temperature of 105° and a respiration rate of 19 or 20 were commonly noted. Exceptionally a very rapid pulse was noted in pneumonia cases. In a few instances bradycardia was observed. A rapid pulse was not uncommon during convalescence from influenza, especially after exertion.
The respiration rate in influenzal pneumonia was not increased to the degree that would be expected from the nature of the lesions in the lungs. The rate was usually below 30. "Whenever the respirations exceeded 24 per minute, pneumonia was suspected, and this suspicion was strengthened if the sputum was bloodstained, excepting when pleuritis caused the increased respiratory rate." Breathing was free but shallow and frequently became very rapid upon exertion. In such cases the form of cyanosis alluded to above appeared to be due, in part at least, to changes in the constituents of the blood leading to air hunger without causing great distress in breathing. With the development of pulmonary edema cyanosis increased, dyspnea became marked, the breathing was rapid, the patient was delirious, and there was great restlessness. "This distressing terminal stage, with the bubbling r’les, frothy sputum, the too vivid picture of heaving chest, cyanosis, and air-hunger facies, will remain as a nightmare of those of us who dealt with these cases in large numbers."
Cough.--Cough was a very constant sign and ranked next after headache in occurrence during the first 48 hours of the disease. There were few cases in which cough did not occur at some stage of the disease. It occurred in from 80 to 85 per cent of all cases of influenza.
Of 352 cases of influenza admitted to the United States Naval Hospital, Philadelphia, Pa., within 24 hours after the onset of the disease, cough was present in 67 per cent and was the chief complaint in 8.5 per cent of the cases thus early in the disease.
Moderate in severity, "dry" or "hacking" at first, and usually accompanied by "tightness" or "soreness" in the chest, the cough loosened rather promptly as a rule and the sputum became abundant. Statements with regard to cough varied considerably in different reports. "Frequently, on the second or third day, patients complained of 'tightness' or 'soreness' of the chest, and there appeared a bronchial cough, moderate in severity, which was productive of large amounts of greenish or whitish mucoid sputum." "Cough developed early in most cases, with definite pain in the chest." The larynx was frequently involved in the course of influenza with resulting laryngeal cough and aphonia. This condition rarely lasted more than a week, and often there seemed to be very little discomfort from that source. During epidemics many persons who did not become acutely ill developed laryngeal or bronchial cough which persisted for several weeks. Few patients actually ill with influenza escaped bronchitis of some degree, and even in mild cases cough was sometimes very distressing and persistent during convalescence. "This persistence of mild bronchitis, with little cough and little or no sputum, should make one careful not to discharge men too early to duty where exposure may precipitate another attack."
With the development of influenzal pneumonia the character of the cough was modified by the nature and extent of the lesions in the lungs and the degree of pleural involvement. Some of the pneumonia patients had very little cough in proportion to the physical
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findings. When sputum was raised with difficulty the cough was frequently most distressing, paroxysmal in character, and interfered with sleep. When the sputum was abundant it was generally evacuated without difficulty until the patient became too weak to cough effectively, when even with the lungs full there was sometimes no coughing at all.
Sputum.--In uncomplicated cases of influenza the sputum was mucoid at first and later muco-purulent and rather thin, grayish or greenish in color. The amount varied considerably but it was usually moderately abundant after the first two or three days. In exceptional cases there was little or no sputum. In some apparently uncomplicated cases the sputum was rusty or tinged with blood.
In cases of influenzal pneumonia the character of the sputum varied from a thin, watery, bloody fluid resembling diluted red paint, to bloody pus and in later cases and cases of prolonged duration pur greenish or yellowish pus. Destruction of erythrocytes and admixture of free blood pigment with the sputum led to a variety of colors; red, rusty, dark brown, and even black. In some cases the bronchi were filled with fluid; in others the sputum was scanty, but in most cases all through the disease the amount of sputum was more abundant than in ordinary cases of pneumonia. The sputum was frequently recorded as frothy. The more purulent the less froth it contained, as a rule. In the terminal stage with pulmonary edema froth was commonly noted.
Hemoptysis.--As noted above, blood or blood coloring matter in the sputum was of very common occurrence. Actual hemorrhage into the lungs and into the bronchi occurred not infrequently in the pneumonia cases. Undoubtedly hemoptysis was due in many instances to the escape of blood from the intensely congested bronchial mucous membrane. At the United States Naval Hospital, Great Lakes, Ill., it was noted that hemoptysis frequently preceded the development of pneumonia and sometimes continued throughout. All degrees from bloody froth to frank hemorrhage were observed. In reports reaching the bureau no mention was made of fatal pulmonary hemorrhage or of an instance in which death could be attributed to the loss of blood rather than to infection and toxemia.
Epistaxis.--Hemorrhage from the nose was quite commonly associated with influenza in uncomplicated cases as well as with influenzal pneumonia. In Philadelphia, epistaxis occurred in 9.7 per cent of the 900 cases treated in hospital, and in one instance it was necessary to resort to packing and intramuscular injection of serum. Bleeding was frequently due to venous engorgement without evidence of inflammation. The blood seemed to ooze from the mucous membrane and usually no ulceration could be detected. On board the U.S.S. Leviathan epistaxis was observed in 20 per cent of the cases as a very early manifestation of influenza. In the receiving ship at Norfolk, Va., epistaxis was troublesome in 6.2 per cent of the 962 cases of influenza, and it was noted that in every case with intense headache the headache was greatly relieved with bleeding from the nose. Bleeding of some degree was observed in 30 per cent of the 962 cases and, in general, epistaxis bore no relation to the severity of the disease as it occurred in many of the mildest as well as in many of the most severe cases. It is noted in a report from the U.S.S. Northern Pacific that free hemorrhage from the nose occurred
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in many cases with general improvement in the condition of the patient; so much so that venesection was later practiced in severe cases with good effect. At the United States Naval Training camp, detroit, Mich., hemorrhage from the nose occurred in about 40 per cent of all cases of influenza and in some instances was very profuse. In all cases bleeding was limited to the anterior nares. On board the U.S.S. Wilhemina epistaxis occurred in practically all patients whose symptoms were of moderate severity.
At the United States Naval Hospital, Great Lakes, Ill., acute nasal hemorrhages occurred in a number of cases, apparently with beneficial results. In 9 among 2,924 cases of influenza, epistaxis was sufficiently severe to require packing. Ulcers of the septum were found in four cases.
Tongue and throat.--There was nothing characteristic about the tongue in ordinary influenza cases. In those which were severe or complicated the tongue was usually dry and leathery or it presented a dry beefy red surface covered with glairy mucus.
Sore throat occurred in about 20 per cent of the 900 Philadelphia cases and was the chief complaint in from 3 to 5 per cent. In Norfolk, slight soreness of the throat was a common manifestation. At the height of the epidemic in Boston it was noted that sore throat was not complained of in typical cases. In cases among the naval personnel in France, throat symptoms were few. In the Philippines, sore throat was a prominent symptom in many instances. On the whole, the throat was often congested but usually the patient did not complain of soreness. In the Great Lakes series streptococcus sore throat was occasionally observed. "The patient may or may not have sore throat in the very early stages of influenza--usually not. Not infrequently patients attributed the attack of influenza to a slight sore throat a few days previously, but he majority gave no history of previous illness."
Adenitis.--In a report from the United States Naval Hospital, Philadelphia, Pa., it was noted that a general adenitis was very frequently discovered upon examination. The whole chain of superficial glands was often involved, including the cervical, axillary, epitrochlear, and inguinal glands. Enlargement persisted during the course of the disease, but the glands seldom became larger than a pea or bean.
At the United States Naval Hospital, Great Lakes, Ill., cervical adenitis was seen occasionally and suppuration occurred in four instances among 2,924 hospital cases of influenza.
Blood.--In uncomplicated cases of influenza the leucocyte count was rarely above normal and usually below normal. In fact, a definite leucopenia was a striking feature and a most useful diagnostic sign in influenza all over the world.
The following is a composite blood picture in 100 uncomplicated cases of influenza:
THE REST OF THE ARTICLE CAN BE FOUND AT:
http://www.history.navy.mil/library/online/influenza_secnavptaa.htm
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