PRACTITIONER LOS ANGELES, JANUARY, 1919 Associate Editors, No. 1 dley, Dr. W. W. Watkins, Dr. Ross Moore, Dr. George L. Cole, . Reynolds, Dr. William A. Edwards, Dr. Andrew W. Morton, 1. D'Arcy Power, Dr. B. J. O'Neill, Dr. C. G. Stivers, . Olga McNeile, Dr. W. H. Dudley, Dr. J. M. Mathews. INFLUENZA AND AFTER. _ssion of Influenza, with Special Consideration of the Com plications and Sequelae. BY GEORGE E. MALSBARY, M.D., LOS ANGELES. on of the chest is comthe use of the X-ray, mination of the sputum hout the use of the mimay be supplemented, supplanted by the most or the most acute diagEven the laity are begnize the laxity of the attempts to treat disLest without the aid of agnosis. The profession general recognition of ■e X-ray examination is ance in diseases of the actures of bones, for in is often at stake, e other case there is formity and impaired considered. No reputavadays treats fractures of the X-ray in diagability of suit for maltly increased by failure , in the cases that teractorily. It will soon putable as it is dangerhe use of the X-ray in the diagnosis of diseases of the chest. Influenza presents characteristic respiratory, gastric and nervous symptoms. Symptoms on the part of the respiratory tract, the gastro-intestinal tract or of the nervous system may predominate in a given case or epidemic. There are also cases that show a marked preference of the disease for the genito-urinary system. The present epidemic has attacked chiefly the respiratory tract, giving a large percentage of pneumonia, and the heart has suffered markedly from the toxic effects of the infection. Many of the cases show empyema, often recognizable more readily or only upon X-ray examination, and not a few of these cases have been rescued by the timely evacuation of collections of pus that would have been overlooked had the X-rays not been used in diagnosis. In a general way it may be said that the X-ray examination of influenza cases during this epidemic reveals four pretty distinct types of the disease. First, there are cases resembling somewhat miliary tuberculosis of the lungs. Second, we have the affection of lobes often going on to consolidation, then constituting influenzal lobar pneumonia. Third, the affection of lobules and the tendency to broncho-pneumonia. Indeed, many are inclined to the opinion that the lobar cases are really cases of lobular infection limited to a lobe. Fourth, we have bronchiectasis, dilatation of the bronchi, which in fatal cases has been found postmorten filled with purulent material. The "consolidation" in the lobar cases is found postmortem to be not so solid as ordinarily found in lobar pneumonia due to the pneumococcus. Upon incision the bloody exudate runs out rather readily, possibly due to the lytic action of the streptococcus, in addition to the lesser lytic power of the influenza bacillus. X-ray examination of cases in this epidemic would seem to indicate that we have been releasing our cases too early. The hilus shadow remains abnormally thickened long after the cases are up and about, and the same is true of the thickening of the bronchi, especially of those of the lower lobes. These changes are usually still quite pronounced six weeks after the beginning of the infection, and often for a longer period. They are very suggestive of the danger of relapse, and seem to explain the slow return of these cases to their normal health and vigor. The slightest pathological lesion of the pulmonary tissue bringing about an appreciable modification in the density of the parenchyma appears as an abnormal shadow upon radiologie examination. By this process new evidence is obtained that is very different from that furnished by other methods, thus increasing markedly the resources of clinical investigation. Heretofore auscultation and palpation and percussion have played a more important part, visual inspection having been content with simply observing the form and contour of the external surface of the chest. With the use of the X-ray, the physician is no longer blind; he may use his eyes as well as his fingers and ears in making a diagnosis. With the Roentgen rays the physician is able to see through the thoracic walls to the deep-seated organs which hitherto were hidden. Their use in difficult cases to explore and examine the topography of pleuro-pulmonary lesions as to their extent and localization, constitutes the "living autopsy" of Claude Bernard. No other method of exploration demonstrates so clearly and simply the funetions of the heart and lungs, which are of so much importance. It shows without the cardiograph the pulsations of the auricles and ventricles and the aorta. It estimates without the spirometer the respiratory value of the lungs; shows the movements of the diaphragm, the intercostal spaces and displacement of the mediastinum in inspiration and expiration. The radiologist must be a physician, if he is to be safely entrusted with making diagnoses. In fact, sight is not everything, but it is necessary to interpret what is seen and to draw conclusions useful for a diagnosis. The difficulty of diagnosis demands a very accurate knowledge of anatomy, physiology and pathology. In certain cases radiologic examination may be conclusive and may totally change the superficial diagnosis. In other cases it will simply confirm the diagnosis. Even when a priori it seems useless, it ought not to be neglected, as it is often in such cases most interesting and furnishes to the physi cian unexpected data. The following are the more important characteristics of the influenzal pneumonia: The invasion is slow and insidious. Bronchitis is prominent. The pulse is slow compared with the temperature, and often there is marked pneumonia with a temperature that is lower than we ordinarily find in pneumonia and often actually remittent. There is marked tendency to early heart failure and cyanosis. Rusty sputum is frequently absent. There is a strong tendency to delayed resolution. Often the consolidation seems to wander from one lobe to another, or from one part of a lobe to another, and it is not uncommon to find involvement of the apex. Furthermore, the fatality and infectiousness of influenzal pneumonia far surpass those of the ordinary forms of pneumonia. Neuritis is common, especially during convalescence. Arthropathies, especially pains in the joints, sometimes acute arthritis, add interest to the convalescent period. Otitis media, double or single, is quite a common complication. is Pleurisy, especially empyema, prominent in this epidemic. Especially in military practice, many of these cases have been recognized through the routine use of the X-ray, and have been rescued by early evacuation of the collections of pus. Tachycardia may be observed. More often there is bradycardia. Angina pectoris is rather rare. Myocarditis is common, less often we find pericarditis. Many of the cases show renal congestion, less often nephritis. Thrombophlebitis is not uncommon. Injection of the conjunctiva is rather common, less often there is actual catarrhal conjunctivitis, and still more rare iritis and optic neuritis. Psychoses may be observed in predisposed individuals. Prostration and general weakness are the rule. Delirium and hallucinations may appear within a few hours. It is well to remember that permanent insanity may be a sequel of influenza. Possibly of most general importance is the aggravation of renal, cardiac cava. The frontal or anterior position, with the patient facing the screen or plate, the rays passing from back to front, is one of the best for obtaining a view of the whole thorax. In this position the median shadow is formed by the vertebral column, the sternum and all the organs of the mediastinum, particularly the large vessels, the aorta, pulmonary artery and venae cavae. Normally, the form of this shadow is quite regularly rectilinear in the upper twothirds of its right border. The middle third corresponds to the superior vena The lower third presents quite often a rounded dilatation corresponding to the contour of the right auricle. The left border is composed of three successive arches. The first of these arches, situated at the top, just below the internal border of the clavicle, is the aortic arch. The middle arch is the pulmonary artery. The inferior arch represents the contour of the left ventricle. Upon roentgenoscopic examination, the pulsations in these regions show clearly the alteration between the pulsations of the ventricle and those of the pulmonary artery and the aorta. The median shadow shows the hilus of the lung, rendered less distinct upon the left by the shadow of the heart. In the pathological condition this shadow is enlarged, elongated and very perceptibly thickened. Hypertrophied and inflamed glands, to consolidation, then uenzal lobar pneumo affection of lobules 7 to broncho-pneumonia. inclined to the opinion cases are really cases tion limited to a lobe. bronchiectasis, dilataonchi, which in fatal found postmorten filled aterial. The "consolilobar cases is found De not so solid as ordilobar pneumonia due coccus. Upon incision te runs out rather readto the lytic action of is, in addition to the er of the influenza bac form and contour of the external sur- ation of cases in this seem to indicate that releasing our cases too is shadow remains abened long after the d about, and the same e thickening of the ally of those of the ese changes are usually punced six weeks after of the infection, and ger period. They are of the danger of reto explain the slow recases to their normal .. pathological lesion of issue bringing about an ification in the density ma appears as an abupon radiologic exams process new evidence at is very different shed by other methods, markedly the resources estigation. Heretofore ■ palpation and percused a more important spection having been pneumonia with a temper The radiologist must be a physician, if he is to be safely entrusted with making diagnoses. In fact, sight is not everything, but it is necessary to interpret what is seen and to draw conclusions useful for a diagnosis. difficulty of diagnosis demands a very accurate knowledge of anatomy, physiology and pathology. The In certain cases radiologic examination may be conclusive and may totally change the superficial diagnosis. In other cases it will simply confirm the diagnosis. Even when a priori it seems useless, it ought not to be neglected, as it is often in such cases most interesting and furnishes to the physician unexpected data. Pleurisy, especially 1 Tachycardia may be ob often there is bradycar pectoris is rather rare. common, less often we fin Many of the cases show tion, less often nephrit phlebitis is not uncommo of the conjunctiva is ra less often there is act conjunctivitis, and iritis and optic neuritis. Psychoses may be obs disposed individuals. general weakness are lirium and hallucinations within a few hours. It member that permanent be a sequel of influenza. Possibly of most gener is the aggravation of 1 The following are the more important characteristics of the influenzal pneumonia: The invasion is slow and insidious. Bronchitis is prominent. The pulse is slow compared with the tem still Pr th often actually remittent. marked tendency to early are and cyanosis. Rusty Frequently absent. There is endency to delayed resolu the consolidation seems to m one lobe to another, or part of a lobe to another, not uncommon to find inof the apex. Furthermore, - and infectiousness of influmonia far surpass those of y forms of pneumonia. is common, especially durescence. Arthropathies, esins in the joints, sometimes itis, add interest to the coneriod. Otitis media, double s quite a common complica especially empyema, is in this epidemic. Especially practice, many of these e been recognized through use of the X-ray, and have ed by early evacuation of ons of pus. -dia may be observed. More e is bradycardia. Angina rather rare. Myocarditis is ss often we find pericarditis. he cases show renal congesoften nephritis. Thrombos not uncommon. Injection junctiva is rather common, there is actual catarrhal tis, and still more rare optic neuritis. es may be observed in prendividuals. Prostration and eakness are the rule. De■ hallucinations may appear Few hours. It is well to renat permanent insanity may 1 of influenza. of most general importance gravation of renal, cardiac diseases. In the examinationn of the chest radiologically, the fundamental positions for taking plates are the frontal or anterior, dorsal or posterior, the right and left transverse, and the right and left oblique. Most essential is the selection of the best position for demonstrating a lesion, with the use of the roentgenoscope, then taking the plate with the patient in that position. The frontal or anterior position, with the patient facing the screen or plate, the rays passing from back to front, is one of the best for obtaining a view of the whole thorax. In this position the median shadow is formed by the vertebral column, the sternum and all the organs of the mediastinum, particularly the large vessels, the aorta, pulmonary artery and venae cavae. Normally, the form of this shadow is quite regularly rectilinear in the upper twothirds of its right border. The middle third corresponds to the superior vena The lower third presents quite often a rounded dilatation corresponding to the contour of the right auricle. The left border is composed of three successive arches. The first of these cava. arches, situated at the top, just below the internal border of the clavicle, is the aortic arch. The middle arch is the pulmonary artery. The inferior arch represents the contour of the left ventricle. Upon roentgenoscopic examination, the pulsations in these regions show clearly the alteration between the pulsations of the ventricle and those of the pulmonary artery and the aorta. The median shadow shows the hilus of the lung, rendered less distinct upon the left by the shadow of the heart. In the pathological condition this shadow is enlarged, elongated and very perceptibly thickened. Hypertrophied and inflamed glands, |