mssis. THE IHPLUENZA PAEBEMIC OF 1918 As Seen At a Casualty Clearing Station In France. E. J. Boome, M.B.,Ch.B.,D.P.H. (Birm,) Capt., R.A.M.C.T.F.

Transcription

1 msss. THE IHPLUENZA PAEBEMIC OF 1918 As Seen At a Casualty Clearng Staton In France. E. J. Boome, M.B.,Ch.B.,D.P.H. (Brm,) Capt., R.A.M.C.T.F. October

2 Unversty of Brmngham Research Archve e-theses repostory Ths unpublshed thess/dssertaton s copyrght of the author and/or thrd partes. The ntellectual property rghts of the author or thrd partes n respect of ths work are as defned by The Copyrght Desgns and Patents Act 1988 or as modfed by any successor legslaton. Any use made of nformaton contaned n ths thess/dssertaton must be n accordance wth that legslaton and must be properly acknowledged. Further dstrbuton or reproducton n any format s prohbted wthout the permsson of the copyrght holder.

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5 UJTRODUCTIOB. Durng the past three or four months. May to July, 1918, there has been a great pandemc of so-called nfluenza whch, startng n Span, has spread over the whole of Europe and even other parts of the world. It has caused consderable wastage n our own Army and those of our Alles and has, therefore, been the object of much study amongst the medcal Servces, Durng ths perod cases sent down to us as P.U.O. showed a great ncrease and presented sgns and symptoms whch had not been prevously recognsed as formng part of the usual clncal pcture, loosely covered by the pseudo-dagnoss of P.U.O. (pyrexa of uncertan orgn). The varous types of nfluenza wth whch we have become acquanted n prevous epdemcs have all been represented, but have to some extent been modfed by war condtons. So close was ths resemblance and so dstnct the* lne of demarcaton that the dagnoss of nfluenza had supplanted that of P.U.O. long before bacterologcal evdence was conclusve.

6 STATISTICS. The present epdemc of nfluenza was really at ts heght about the mddle of June and was then recognsable as an ep demc of some dmensons. In the attached table, t was consdered that all cases of P.U.O* should be ncluded as part of the epdemc. After re peated examnatons,n the great majorty of cases sent down as P.U.O. durng ths perod t was found that the symptoms pre- * sented were those of nfluenza. Agan, the respratory type of nfluenza was sent down as bronchts and these cases are ncluded. Darrhoea cases often turned out to be pure nfluenza. One case was sent down as tetanus.

7 3. NO. C.C*S» PERIOD 12th JUHE to leth JULY NUMBERS OF CASES DIAGEOSED AS:- ADM. IBASB j IDUTY - bsd 1 IADM.IBASS IDUTY * s 404 ^84 P. U. 0. IBFIUEflZA BR. PHEUMOHIA LOB. PNEUMOHIA l r DIED &DM. BASS DUTY bna> r T &ntf. BASS DUTY - ~-r --- r-- 14 IL 73! L085! t t ' ' a - k+a DIED 1 BROKGKITIS AXU. 38 BASE 37 DUTY j DIED 13th July, 1918

8 TYPES. I have not attempted to enumerate the varous types, Toe- cause of the tendency for them to be merged nto one another; bat have rather tred to dscuss them under the headng of symptoms or generaltes. Some of the cases I have added llustrate ths. Such was the vrulence of the dsease n certan cases that the patent mght be consdered to be sufferng from all the four usual types, e.g., Respratory, Nervous, Gastrontestnal and Febrle. I was partcularly mpressed by the frequency of kdney complcatons, that,1 have called the paragraph "Hephrts", a subject n whch physcans at the front are ex tremely nterested. I have, unfortunately, been unable to delve n the lterature on the subject, as of necessty our \ medcal books were lmted to essentals, owng to dffcultes of transport.

9 IHCUBATIOH PERIOD. Ths was dffcult to establsh, as there were so many sources of nfecton, but t seemed to be rom two to four days. Une was often told that a lot of men were taken ll suddenly n a dugout or bllet about two days after one of ther number had been sent down sck. Two gas cases jchlorarsene^ ^J had no symptoms of nfluenza, developed a temperature, pans n the lmbs, cough after beng n the acute medcal ward after two days. I am nclned to thnk that those men were nfected n the ward and that ther symptoms then were not due to the gas. OUSET. Almost nvarably the onset was very sudden and often the patent could say what he was dong at the tme, e.g., he was on pcket, on sentry, or was cleanng hs horses,- when he felt ll. Tery few men gave a hstory of a gradual onset, these only complaned of feelng "a bt out of sorts" a few hours before beng taken ll. Several men stated that they collapsed on the march.

10 SEGREGATION. Specal tents were reserved, as far as possble, for nfluenza cases. But t was qute mpossble to secure absolute segregaton.a common recevng ward s used for all cases, whether sck or wounded. Sometmes t was necessary to evacuate nfluenza cases and wounded n the same car. It was noteworthy that among the orderles lookng after the nfluenza tents not one contracted the dsease. RASESS. Rashes were very rare. Several cases showed a brght erythema on chest and abdomen whch usually lasted a few hours only. A few oases showed a dscrete maoular rash on the trunk, not unlke the rose spots of enterc. In one case t was thought that t mght be one of the enterc group. Blood cultures and bacteral examnatons of faeces were repeatedly negatve but a West swab showed pneumococc and "pvfeffer. Two cases presented a rash not unlke that of a Rose Measles; these.were thought to have been, btefea^rug rash, tarn due to ether Saloylate of Soda or Antpyrn.

11 7. RASHES (Contnued). One case had a dusky nodular rash, on Ma chest, axllae and abdomen - he was n a partcularly toxc condton and eventually ded. Urtcara was frequently met wth n the form of large weals, whch were ntensely rrtatng. PIKK EYE. Conjunctval nfecton was the rule at the onset, but n most cases dsappeared rapdly. A few oases presented a very marked nfecton, wth waterng of the eyes - so much so that one began to wonder f they had been gassed wth mustard gas. Ths was found not to be the case and was really part of the condton.

12 8, BESPIRATORY SYMPTOMS. In the mld cases, the majorty complaned of a "rawness down the sternum", wth pan on coughng, whch could be ac counted for by an acute trachets. found. A few rhonc here and there n the chest were also generally In the less mld cases, rhonc and muscal rales were found, ndcatng that there was a broncholts, or congeston at the bases, whch would possbly go on to broncho-pneumona; n the great majorty of cases, the physcal sgns cleared up, the pat ent was able to return to duty or to be evacuated to the base for convalescence, dependng on the mltary crcumstances at the tme. The severe oases presented the usual sgns of broncholf\a»lvu«q pneumona, patches of bronchal hfeatbng here and there and hypo- statc congeston at the bases. The latter condton not nfrequently resolved n two or three days under treatment. Pleursy was a qute usual symptom n the severer cases, and caused the patent a great deal of ntense pan. Pleural effusons, strange to say, were very rare n the frst part of the epdemc; t s possble that they developed later n cases who were evacuated, but n the acute stage when

13 9. RESPIRATORY SYMPTOMS (Contnued). they were under my care, only two cases occurred n over two thousand oases. Lobar pneumona, arsng as such, I am nclned to thnk dd not occur. I am convnced, by very careful watchng of the physcal sgns n the chest and p.m. appearance that all oases of marked consoldaton orgnated as a lobular pneumona gong on to complete consoldaton of one or other lung. Durng the latter part of the epdemc, I have had a good numbed of pleural effusons, who generally gave a hstory of nfluenza about three weeks before. One patent had been dong fatgues untl the day before admsson here, when he "felt fant and could not get hs breath". He was asprated * 1^81. removed from hs rght chest!! Durng the past ten days I have had three cases of nterlobar empyema. These cases were sent down to us as bronchopneumona and certanly had the ordnary physcal sgns of bronchopneumona at frst and then, after repeated examnaton, one found an area of dulness whch was surrounded by feeble breath sounds or tubular breathng. Ths area was explored and pus found. The more chests one lstened to durng ths epdemc the more one realzed the dffculty of recognsng the obscurer lung condtons.

14 10. RESPIBATOBY SYMPTOMS (Contnued). The detecton of flud or consoldaton was often extremely dffcult, and there was often a combnaton of the two; ths dffculty was thus ncreased. Apcal pneumona occurred n two of my cases. One day one would hear a small patch of tubular breathng, the next day frcton, and so on. The physcal sgns changed even from day to day and the most careful watch for flud or consoldaton was necessary. It was mperatve to treat symptoms as they arose, owng to the severe nature of the nfecton. Ths varaton of symptoms gave opportunty for followng out closely the clncal sgns produced by the very rapdly changng condton of the lung. SPUTUM. In the slght cases, there was none, or extremely lttle. If. the case became more severe, there was at frst the ordnary mucous sputum of bronchts, whch, however, as tme went on became greensh-yellow, wth round lumps (nummulated). Ths was very notceable n a large number of cases. When broncho-pneumona set n, the sputum was often rusty and n large quantty. In fve cases the sputum contaned a large quantty of blood for some days. Repeated examnatons of ths

15 11. BESPIRATORY SYMPTOMS (Contnued). latter knd of sputum revealed no tubercle bacll, only nfluenza bacll or pneumooocc, and usually both. It was nterestng to note that n practcally evefy case where there was a large quantty of blood n the sputum, that the patent's condton cleared up relatvely more rapdly and only one death occurred.

16 12. GASTRO IETESTIHAL SYMPTOMS. It has been suggested that the present epdemc s not due to the nfluenza bacllus, on the grounds that gastro-ntestnal symptoms and the other complcatons of nfluenza were not present. That has not been my experence. Gastro-ntestnal symptoms were often very marked. Several cases presented symptoms of an acute gastro-enterts wth ether very lttle chest symptoms or concomtant wth a broncho-pneumona. Prolonged attacks of vomtng often occurred at the onset and contnued untl the temperature dropped. Darrhoea was a not uncommon symptom; blood and mucus were noted n two cases. Specmens of these were sent to the laboratory on the off-chance that they mght be cases of the dysentery- -enterc group, but were reported negatve. General abdomnal tenderness was a feature and n sx cases there was a defnte tender spot over McBurney's pont. These cases were sent down to us as appendcts, but under the usual treatment adopted for flu cases they rapdly cleared up. Fve cases dagnosed as appendcts were n all probablty nfluenza. Two of these cases presented symptoms that warranted an opnon as to the advsablty of surgcal nterference. One

17 13. GASTRO UfTESTIHAL SYMPTOMS (Contnued). case was operated on and the appendx removed. The appendx was found to be congested but not thckened and had undoubtedly set up an appendcular colc wth local tenderness. In several cases t was extremely dffcult to decde whether they were of the enterc group or smply those of the prevalng epdemc. In the case of No. 4E77, the notes of whch are appended, blood cultures and examnatons of the faeces were all negatve to the enterc group. At the autopsy, whch was not unlke that of an enterc, swabs taken from the larger bronch showed Pfefferte bacll and pneumococc. Jaundce occurred n three of my cases, one of whom (notes appended) was n the typcal typhod state, e.g. oarphology, mutterng delrum and restlessness, relapsng nto a state of stupor and death Pte. E.G. E. 7th Yorks and Lanes. Br. Pneumona. No Notes from Feld Ambulance. Admtted to 56 C.C.S Temp Was not examned but sent drect to ward as he was extremely ll and delrous Notes n Ward. Very delrous. Very dffcult to examne. B.S. Bronchal Rt. base. Frcton left base. Abdomen tender. Hardly ratonal; complans of pans n the belly.

18 14. GASTRO INTESTINAL SYMPTOMS (Contnued) Farly quet nght. Stll delrous. Rt. lung: Consoldaton. Left apex Bronchal Breathng P.N.du.'H. Creps left base. Patent got steadly worse and ded at 5 p.m. Post Mortem examnaton: Lungs: Fresh adhesons everywhere. Bronohopneumona both bases and left upper lobe. No flud. Bact. Bxam; from bronch. Drect smear - shewed pneumococc and nfluenza. Heart; Fatty. Enlarged. Petechal haemorrhages n percardum. Early percardts Rt. aurcle. Lver: Pale. Intestnes: There were sx patches of subserous haemorrhage n the mddle of the lum. Two soltary follcles were found to be swollen, congested and nflamed. Cultures from these showed - acd and gas n Dulcte and Mazuate. No Influenza. Spleen; Enlarged 1^ tmes. Kdneys: Pale.

19 15, GASTRO IKTESTIHAL SMPTOMS (Contnued) DT. H.J. 293 Army Bde. R.P.A. Br onchopneumona, followng Influenza. F.A. Motes. Went scfe on 2, and pans all over, headache, pan n chest, cough. July July P P Admtted to the 56 C.O.S Sudden onset four days ago - shverng. Influenza. Pans n chest, cough, looks very ll. Haemoptyss Blood- staned sputum. Breath very foul. Tongue very drty. Very deaf. Fauces nflamed. Urne - dense cloud, albumen, blood. Left lung. Frcton axlla, creps base. P.N. - Br.Br. behnd. Rght Lung. Crepe base, n front and behnd Very toxc. Br.Br. rght base and axlla. Jaundced at 6 p.m. Delrum. Carphology Jaundce ncreasng. Very foul breath. Lstless. Rt. base Creps^n Br. Br. Urne very scanty and ble staned Br. Br. rght base, very jaundced, much worse Patent got very much worse and ded at 7.30 a.m.

20 ]>atb8 of Observaton T?tnp«rnAr«, l''ohrenhrr s " 105 f DUeaso I8 a T-mATn Rank and Name..'.-..' U.t- of admsson r!» Ttmo 1 I'lmc " s Tmn ^ CLINICAJL CHART. to Cane j ^ 1 _[_ -f ftn ; <. JM Tn.r # Mltary IIosptaL. Servce Ts.r Tmrxn PlHfllllt.'.rts Tnjfj 1 Tmu' 1 Tm,. Army Form B Tnn- T,,,, 1! ^r,,,,.^,,,. 104' > 101" 100' a ;a I ' 3 C0 vt A 97 lluuto lotons per 24 Houra ; -- s 1 lb x --U l^ Wt a. * 8). (1MI3)- l.r.b. lll/ IE. 735) 1 ' I 1 ' ']/ -H Sgnature..In charge of cuse.

21 1 Corps Dsoa-sc DuUn of Utovrvatkn I>\-<..f Dsease No. 1! "Rank and Xamc 1'. ' -I CLINIC' (To be a.''; n. A TP Mltary Hosptal Sot vcf Army Form B p 107' 105* 104" 103" ' J 98 7' e 4 a a «4 a 4 a a e a 4 a a B 4 3 a v a 4 a a ;e a a e 4 a > r\\»o jver Mnute He*pntona per Munto Jutlunn per um Wt. WI7tt/lla>l» %000,«M-4Y17 H. * Sp. (1MM) A.F.B. 111/5 (E. 7» t 1 \ 1 I Sgnature..In ehargv of.

22 16. GASTRO INTESTINAL SYMPTOMS (Contnued). Post Mor-tem Bxam: Rght Lung: Lower and mddle lobes consoldated. Upper partally wad bronohopneumonc patches. Fresh adhesons. Upper and mddle lobes had patches of necross. No flud. Left Lung; Lower lobe - red hepatsaton. Bronchopneumonc patches. Markedly adherent. No flud n chest. Stomach: Markedly congested. Pylorus very thckened. Duodenum: Inflamed and swollen. Much mucus. Jejunum and Ileum; Very congested. Appendx; Inflamed and knked. Kdneys: Accessory ureter left. Enlarged and nflamed; probably acute parenchymatous nephrts. Capsule strps Spleen: Enlarged. Lver; Fatty, almost nutmeg. Heart: Fatty degeneraton. Heart muscle pale and flabby. On aortc and mtral valves fresh vegetatons. Barly percardts of rt. aurcle. Blood culture - sterle after four days' growth. Faeces: negatve to dysentery - enterc group.

23 17. GASTRO INTESTINAL SYMPTOMS (Contnued). The followng case s added n that t shows a case of cascara sagrada"posonng, complcatng nfluenza. Pte, F. R.A.M.C. P.Amb. Orderly. Feld Amb. Notes; Onset of llness Patent was admtted to P. Amb. for "Deblty and D.A.H." On the evenng of the he complaned of headache and pan behnd the eyes and pans all over, and was dagnosed as nfluenza. Bowels had been moved daly but not well for several days. About 1 a.m pan commenced n the abdomen and localsed to epgastrum. He was kept awake by the pan. He commenced vomtng at 5 a.m. and at ntervals of half an hour snce then. Vomt conssted of partcles of food at frst, then mucus wth occasonal streaks of blood. Every tme he vomted he was oblged to go to stool lb. Motons very loose now; at frst tney were very costve. He stated that he started takng cascara sagrada tablets on the Sunday prevous and n 4 hours consumed twelve tablets. They had no effect on the bowels untl to-day. Re took the plls "on hs own account". They were not ordered by hs medcal offcer. Has not taken anythng else.

24 18. Tongue coated and drty. Occasonally has hccough, pan n epgastrum and lac regons. No rgdty. He looks pale and a lttle collapsed. Pulse 78, feeble. Temperature subnormal. Admtted to C.C.S Darrhoea, vomtng. Bowels moved about 10 tmes to-day. Hccough. Pan n the abdomen. Pnk eye. T.101. In Ward. Epgastrc pan and tenderness. Foul tongue. Vomted. Trace of blood n stools. Pupls dlated Vomted (ble staned). Epgastrc tenderness. Tongue cleaner. Nl n chest. Two stools only durng nght, trace of blood Not vomted; much better. Evacuated to the base.

25 19, HEPHRITIS. Practcally every case durng ths epdemc has had albumnura wth or wthout blood. Cases wth a large amount of albumen and blood have been sent down to us as Hephrts and not Influenza. The condton found n these nephrts cases s qute unlke the ordnary nephrts or any form of war nephrts. In the extracts from the Research Commttee's Fndngs t wll be seen that these cases dffer n almost every partcular, lo^t 2. f. j The onset s nvarably sudden and smlar to that of nfluenza, and often the condton that caused the man to report "sck" was because he notced that hs water was "bloody". Ho hstory of prevous nfectons dsease - e.g. S,F. - was dscovered n twelve cases. Exposure would hardly play an mportant factor as t s summer, and the weather has been relatvely fne V\ ^ A L ^P There was no oedema of the extremtes notced n any of these oases, and nothng to draw attenton to the case beng one of nephrts from a superfcal glance at the patent, beyond very slght puffness of the eyes, whch was exceedngly transtory. Lookng at sx nephrtc patents amongst a ward of twelve. I have now under my care, I thnk the keenest observer would fal even to hazard whch were the nephrtc cases. About half the cases had a few rhonc, but there was no severe respratory trouble, except to the more advanced cases of

26 20. NEPHRITIS (Contnued). serous bronchopneumona, who also had a large quantty of albumen and blood. No enlargement of the heart was noted n the mld cases. Headache was slght and the patents occasonally complaned of pans n the lmbs and backache. The blood pressure was consstently low and the only case above normal I fare no ted was 140 and that rapdly came down to 115, and ths was n a man who was a mner n cvl lfe, aet 25. The usual pressure noted was about 100 mm. for the systolc pressure and about for the dastolc. The systolc-dastolc nterval seemed to keep farly constant. There was a large amount of albumen and blood n these oases but under treatment the albumen tended to clear up rapdly and the blood dsappeared n all but the very severe cases after the second or thrd day. Mcroscopcal examnaton of the urne showed red blood corpuscles n a greater or lesser number, but was constantly present n the cases examned; leucocytes, a few granular caste were occasonally met wth, and n two cases epthelal casts. Phosphates were noted n one case. The quantty of urne passed vared from oz. Suppresson of urne dt not occur n the cases uncomplcated by bronchopneumona showng a more ntense nfecton. The case

27 21. MSPHRITIS (Contnued). of Sgto R, (1/5 Man.) s llustratve of ths more vrulent type. Wth the severe bronchopneumonas, I had several cases wth sup presson of urne and dffculty n mcturton. Wth the frst oases admtted one was nclned to look on them as a prmary aoute nephrts, but on nvestgatng the on set and by bacterologcal examnaton of the nasopharynx, where the nfluenza bacllus was recovered, one realsed that they were part and parcel of the present epdemc. Post-mortem examnatons also revealed n nne cases en largement of the kdneys, wth much njecton. Sgt. R. 1/5 Man. Br. Pneumona Sudden onset whlst restng. Headache, pans n back and legs, cough, weakness, vomtng P.H^jBoth bases Br.Br<\t\patehes - very toxc Pan n rght sde; frcton. S VW * S Y Frcton SGlft/&r. left axlla, herpes, ^sod.bo.tvta Creps. both bases, delrous durng nght. Pne crops rght lung, coarse rales Much worse; tongue dry; pans n the belly; delrous , 18. Better nght; stll delrous; rt.base P.B. 7,R. ++ Br. Br. L. base P.H.. Fne creps. rght apex; darrhoea, ncontnent.

28 22. NEPHRITIS (Contnued) Urne: Dense oloud of albumen - trace of blood. Abdomen very dstended; spleen -f P.N. - bases Br.Br. n patches, both lungs, behnd. SO\Xr\Ss 30. E. 18. Pseudoorss - heart eebo feeble. Urne - oloud - albumen - blood. s^v^frs Heart S-; 0, S. feeble. Urne - haae of albumen; no blood SovnTte Haze albumen, Eeart B feeble. Very drowsy, apa thetc ery lstless - chest clear - dffculty n mctur ton Evao. lyng - urne, slght haze of albumen. Sgt. W. 1st Eerts. Broncho-pneumona. Feld Amb. Notes - Onset sudden on headaches, pans all over body, sore throat and cough Temp " P Rales both sdes chest. Dulness left base. O.C.S. Notes: Sudden onset wth fantness and sore throat* Could not walk. Pans n the lmbs came on soon after - and headaches.

29 I»:se;s, 'll'.t* (>{ Observaton T- :n;.---f:rr, 1 Dueasc 1, ' 1 L rujlljcu u ' anrl Xamf CLINICAL C! (To Lc,"--' I ' > S,.pv«- l< Army Form B l>tu- of admsson r. ;>-Ml; '!! > 1! O SO / /! 1 107' ^ :S a 105 ^ ^ 102" 2 e * :S *fl 97 :2 a a rul-«- I-.T Mnnt* ll! I ' I 1 II n U.. 1 -v T------VVV -- -rvv]j-v :" - -r-"r 1 -- " ' ;, -V-T-- : -- ; - ;-- -r \, ' - rt-tf r :! 1! I Mnute Motons per 24 QUID* WL WI7 Ift/tfttSJ 1,000,000 1 \M\,-.1/\A I/UK.,. ' ;' IXI^,, V7-H. * Bp. («0<M) A jr.b. u>/ (IL 7381 Sgn^tura In charge of cnue a

30 Corps_ >HUh of Obflorvnu. Davh of M^-n." TtupTnt. 1 lueuhel ' 107" a e B 6 No. Hank aud Name D.tte of admsson Tmr Tm, ^ Prn* Tm,! lme Tnvl Tn-.V P.H. «.M.P M!-"ft"*y4- CLINICAL CHART. (To be attached to Case Sheet.) ^ jjue or ' 1 1. rj'tueltnp j Tn-..,-L «. W. P.M.I >JM.r«A.M.I'M «.W PX. A.M.T.M. IV r y w ^ Mltary HosptaL Servce * ll.pb '^.An A.M r v,t;" M ' - ; ^...,... V I Army Form B ' t,«p.m.: I.K.P.V T--:-- TV T ' '8 t> M:,jte loton* per 124 Iloura \ 4,j "SJ \ 1* I 5 *"' I J ^ V nr " 5 I r,ooo «/: a. 736) _Io charge of

31 23. NEPHRITIS (Contnued). Tongue brown fur - dry - now complans of pans n the back, stomach and chest. Very oyanosed dyspnoec and looks extremely ll. Pulse Cyanoss rather less. Pan n chest. Creps. both soo^fcs bases. Frcton Q.Q.a. left base. Breath sounds very harsh at apces and nclned to be bronchal. Insomna and de presson. Pans n the belly. Suppresson of urne. (After hot fomentatons to belly passed 6. ozsu} Urne very scanty. Bronchal breathng here and there all over both lungs. Cyanoss more marked and patent much worse. Eeart enlarged to rght. Stools very loose Patent got steadly worse and more cyanoss and ded at 2 a.m. Post Mortem Examnaton: Lungs: Pleuropercardal adhesons old. Left long - consoldaton probably lobular at frst, gong on to complete consoldaton of lower and lower part of upper lobe. Fresh adhesons and lymph. No flud. Emphysema at apex. Rght Lung - Lower and mddle lobes practcally sold. Heart: Percardts at rght base of heart. Heart n systole. Eeart muscle congested; rght aurcle and ventrcle dlated.

32 24. BBPHHITIS (Gont nued). Spleen; Congested. Lver: Congested, wth fatty areas. Kdneys: Enlarged - kdney capsule strpa farly easly. Acute parenchymatous nephrts. Intestnes: Jejunum and Ilum very congested and nflamed mucous membrane. Glands of mesentery enlarged and congested. Appendx: Congested. Mucous membrane nflamed; contaned two faecal concretons. No pertonts e fresh lymph. CASES OP NEPHRITIS OCCURRING DURING THE PRESENT EPIDEMIC. I have extracted some of the conclusons of the Medcal Research Commttee on War nephrts as publshed on June 7th, 1918 (No. 3.) n order to afford a comparson between the old war Trench Nephrts and the Nephrts to be descrbed. 1. The onset of the dsease s frequently nsdous and n the majorty of cases there s a hstory of symptoms, extendng for more than two weeks prevous to admsson to feld ambulance.

33 25, HEPHRITIS (Contnued). 2. A hstory of mmedately precedng nfectous processes s nfrequent. Scarlet fever appears to play lttle or no part n the etology of the dsease. In seven oases only was there a more or less defnte hstory of prevous renal dsease. Exposure appears to be a factor n the producton of the llness. 3. The oases seen by us agreed wth the general descrpton of war nephrts n low rate of mortalty, severe respratory symptoms and short duraton of oedema* 4. The blood pressure was constantly rased, the rse synchronzng, n the great majorty of cases, wth the perod of oedema. The rse n the dastolc pressure corresponded wth that of the systolc, but was less marked, the systolo-dastolo nterval beng ncreased durng the perodof rased tenson. 5. Hydraema was present n the great majorty of patents n whom t was looked for. In most cases ths hydraema corresponded to the course of the rse n blood pressure. In some cases the blood appeared to be more dropscal than the tssues, whle n others the reverse held. 6. In a large proporton of the cases defnte enlargement of the heart to the left was present. usually of a temporary nature. In the absence of post-mortem evdence, the nature

34 6. HSPHRITIS (Contnued). of ths enlargement could not be ascertaned. Pte. W. H. Ho th R.W.P. 38th Dv. Age 39 years. Servce 2 years. Prance 5/12. Hever had scarlet fever F.A. dagnoss - Albumnura. Occupaton - gardener. 2 days ll. Wne coloured urne, sudden onset. Darrhoea day prevous - headache and weakness of lmbs - then notced that hs urne was coloured - no oedema Urne, very dense cloud of albumen and blood - no darrhoea. Weakness n the legs. Systolc 115 Dastolc 70 Ho headache* Cloud of albumen, blood, slght occptal headache and pan n hs knees and legs, (and n cvl lfe also) Nl heard n chest; cough. Systolc P. 110 m.m. Dastolc E 70 m.m Urne - dense cloud of albumen, blood, cough, pans n the back of the head. A.B. normal. Pans n the knees. Systolc P. Dastolc P. No enlargement of the heart. 105 m.m. 65 m.m Thn cloud of albumen - blood. Systolc P. 100 m.m. Dastolc P. 65 m.m. Complans of chll n the lower extremtes. Evacuated lyng.

35 Corps_/6j? W f Dsease Dates of Observaton '1 No. ffr <9 10 ^ Rank and Name Date of admsson Days of Dsease Temperature, Fahrenhet B A.M. P.M. A.M.P.M. A.M.P.M A.M.P.M. A.M.P.M. A.M.P.M. AJVI.P.M. A.M.P.M. A.M.P.M. A.M.P.M. A.M.P.M. A.M.P.M. A.M.P.M. A.M.P.M. 107 :a :* _8 105 ;.'8 104 :I!8 103 :a!8 102 :2!8 101 :I "'8 100 :* 8 99 :* 8 98 :« ^ 8 6 Pulse per Mnute Respratons per Mnute Motons per 24 Hours ^ o ct V- ^ <0 VWq f< c< \ J... ^ 0 K ^ ' ** A^ <j CX >*.^ H-* e<ct -«/V> > O /v w c^ V 5* v- Q cv - / Wt. W3728/M2313 2,000,000 8/17 H. & Sp. (10693) A.F.B. 181/5 (E. 735)! 1! j I j j

36 CHART. to Case Sheet.) Date of dscharge Mltary Hosptal. _ Servce Kesult_ Army Form B A. M.P.M, A. M.P.M. A. M.P.M. 4. M.P.M. A. M.P.M. A.M.P.M. A. M.P.M. A.M.P.lrf.! A.M. P.M. A.M. P.M. V.M.F.M..M.P.M.. A.M P.M. A. M.P.M. j A. M.P.M. A.M. P.M. \ M.P.M S V j : 1! j! : Sgnature..In charge of ease.

37 27. HSPHRITIS (Contnued). Pte. I. J st East Surreys. Age 31. Servce 4 years. Servce n Prance 3-3/12 years. Occupaton - brcklayer F.A. Dagnoss - P.U.O C.C.S. " days - onset sdden, wth back ache and headache. T Urne wne colour. Systolc P Dastolo P. 90. Headache and pans all over Evacuated lyng (under pressure) Ts<\'S*.o-*~. Pte. M. R. Ho B.C.L.I. 2nd Dv. Aet 25 years. Occupaton - mner"- no hstory of S.F. 13o P.A. Dagnoss - albumnura ]8. C.C.S. 3 days ll. Tender over bladder. Frequent mcturton. Urne: cloud of albumen. Ho blood Ho oedema of legs. Byes slghtly puffy. Pans n the belly over bladder. Systolc P Dastolc P Urne: Fantly acd, fant haze albumen. Ho blood Urne. Dense cloud of albumen - no blood. Pans n the belly. Systolc P Dastolc P Urne: Cloud of albumen. Ho blood. Mcroscopc examnaton urne: Red blood corpuscles; leucocytes, granular and epthelal casts.

38 NEPHRITIS (Contnued) Pans n belly. Systolc P Dastolc P Urne: Tan cloud albumen -. no blood. Evacuated lyng. Pte. H. A /7 Lanes. Ps. 42 D.W. Age El years - Occupaton Farm Labourer F.A. Dagnoss - nfluenza '. 18. Do. Jf.Y.D. Pyrexa. C.C.S. Dagnoss - nephrts. 3 days ll, sudden onset. Headache and general pan. Pan n lmbs. 9ete8A«y Styfe Rather puffy. Urne test, slghtly acd, dense cloud of albumen. Blood present. Guaeum test. No dff culty n mcturton. Slght headache, backache. Blood pressure - systolc 95 M. dastolc 60 mm Cloud of albumen - blood n urne. B.P. 95 Dastolc 60 num Urne - cloud of albumen - blood prea. pressure 95 mm. dastolc 60 Slght headache. B.W.O Cloud of albumen - blood - systolc 95 dastolc 60 Slght headache. Tongue furred Thn cloud of albumen. Blood. Systolc 95 Dastolc 60.

39 Dates of Observaton Days of Dsease Corps /y / No. ^ Dsease y ^-f^-^ux; /* ^o" t ftt t (» Rank and Name /IrJ9- Date of admsson 20 _. f /.I* CLINIOAI ( r 6<J attached "Vy %/ ^ Temperature, Fahrenhet '8 107 : : B A.M.P.M. A.M.P.M. A.M.P.M A.M.P.M. A.M.P.M. A.M.P.M. A.M.P.M. A.M.P.M. A.M.P.M, A.M,P M. A.M.P.M. A.M.P.M. A.M.P.M. A.M.P.V o4 : a 103 :2!8 102" ' * :* :* :* 8 98 :* ' :* 8 6 Pulse per Mnute Respratons per Mnute Motons per 24 Hours * * \ <., ^^. «t I!^ «<*u, -AV, ' *. 0 *> 1 t ^ M C ~y «f o**..» ISJ <S X ^^ ^«1 1 " ^ ^ \3JV5 ^» cxjffrf * 4 <j («: '/' 1..,!! Wt. W3728/ ,000,000 6/17 H..4 Sp. (10893) A.F.B. 181/5 (E. 735)

40 CHART. to Case Sheet.) Age_ Date of dscharge Mltary HosptaL _ Servce Result. Army Form B «A.M.P.M. A.M.P.M. I A.M.P.M. l.m.p.m. A.M.P.M. 4. M.P.M. A.M.P.M. A.M.P.M. A.M.P.M. A.M. P.M. V.M.F.M. A.M. P.M. A.M. P.M. A.M.P.M. A.M.P.M. A.M.P.M. 1 M.P.M -T. /.. \ - 1 ' j,. _ j!! j. 1 Sgnature. _In charge of

41 29, HEPHRITIS (Contnued). examnaton - red blood corpuscles - leucocytes. Phosphates - no oasts. Pan at the end of mcturton. Tongue furred - nl n chest. SO Urne - thn cloud albumen - Evacuaton lyng. Pte. P. g a05 Bmpt. Coy. Age 19 years - Servce 13/1E.. Prance 4/l. Occupaton n cvl lfe, warehouseman P.A. dagnoss - N.Y.D. Pyrexa. Headache, nausea, dzzness; Asprn gr.v. Mag. Sulp.-^- oz Thck cloud of albumen n urne. Blood C.G.S, dagnoss - EBPHRITIS. 3 days ll. sudden onset, passng much urne, no pan. Urne test: Dense cloud of albumen, blood present «18. Nephrts treatment, no pans, no headache, no oedema of legs. Eather puffy. Systolc B.P. 11 M.M. Bastolc 70 M.M Acd, cloud albumen, no headache. Blood - systolc 105 Dastolc Systolc 100 Dastolc 60 Ml n chest, urne dense, cloud of albumen. Blood.

42 ' ' ' l«t. Corps JO 4)' c Ct Dsease Dates of Observaton Days of Dsease 1* No. */ ft /r f f? /^ -& Rank and Name Date of admsson / K?» Temperature, Fahrenhet a a 106 :* '8! A.M. P-M. A.M.P-M. A.M.P.M. A.W.P.M. A.M. P.M. A.M. P.M. A.M. P.M. A.M. P.M. A.M.P.M. A.M.P.M. A.M.P.M. A.M.P.* 105 3! :2 ;a 102 :2 ;s 101 :2 8 t - ': ;s 99 :* 8 98 : a '6 97- '-I 8 '6 Pulse per Mnute Eespratons per Mnute Motons per 24 Hours A * ' /Or; >a -*; \> Vj >» r- * ft, A «V V 6- <v ^A»» vl^ s^vs ^>!< *v»v * M^A/ \\Q do «N!«V # ^ SI H VI 1 I -" ' ' " J k - ' Wt. WS72I/M2SU 2,000,000 6/17 H. A Sp. (10893) A.F.B. 181/5 (E. 736)

43 CHART. o Case Sheet.) _ Date of dscharge Mltary Hosptal, _ Servce Result. Army Form B. 181.» me P.M. A.M.P.M A.M. P.M. A.M. P.M. A.M.P.M A.M.P.M A.M.P.M A.M.P.M. A.M.P.M. A.M. P.M. A.M.P.M. A.M.P.M..M P.M. A.M. P.M. A.M.P.M. 1 A.H.P.H. A,M.P:* I!! I I 1 Sgnature..In charge of case.

44 30. NEPHRITIS (Contnued) Dense cloud of albumen. Blood. No oedema. Systolc B.P. 95. Bastolc 60. Bo headache; mcros oppo examnaton - red blood cor puscles, leucocytes, granular and epthelal casts Urne - thn cloud of albumen - Blood - Systolc 90. Bastolc 60. Very slght headache Cloud of albumen - blood - Evacuaton, lyng. Pte. L th R.W.F. 38th Dv. / /, h \ ) ~~m*~m*~~~-~-*-~**-,» -IIIIMIII* I ^3 JT^C '*-4 J ' Age - 0 years. Servce 19/l l-^ Prance) 3/12. ^(Has not beenn the lne ). - Freman n cvl lfe. Not had scarlet fever F.A. Dagnoss - Albumnura. 3 days ll, onset sudden, wth dyspnoea, face swollen, polyura, headache. Too-fe.^.*»\ Urne test - thn cloud of albumen, no blood, sudden onset, frequent mcturton. Fan n the stomach and chest, tongue furred. Systolc 100. Bastolc 70. ct cr l* *-**V Urne - haze of albumen - no blood - Systolc 105 Bastolc 70 Evacuated - lyng.

45 31. HBRVOUS SYMPTOMS. Amongst men who were evacuated to us from the trenches there was a tendency to be very hghly strung alternatng wth perods of depresson. Mutterng delrum and carphology leadng to even the typhod state were observed n the more toxc cases, especally those wth a severe bronchopneumona. Some of the men who had been badly shelled presented symptoms of a hystercal nature, and several men burst nto tears on beng questoned. Ths, however, rapdly cleared up wth treatment, and a nght's rest n bed. Pan n the lmbs was a common symptom. I observed only two cases of what one would consder a true neurts. These were of the sdatc nerve. Pleurodytoa was noted n over 40 cases 8 I thought at frst these cases were pleurtc n orgn, but I faled after the most careful examnaton to detect any frcton sounds n the chest. Ths was a very dstressng symptom and was dffcult to cure. I myself had t for some days and realsed that t was an extremely panful condton. The attached ease s llustratve.

46 32. NBKVOUS SYMPTOMS (Contnued). Sgt. P. R.B. Feld Coy. Influenza - (Tetanus). Admtted to C.C.S. on Headache - pans all over and general twtohngs (sent n wth dagnoss of Tetanus and had been gven 1500 A.T.S. before departure from Feld Ambulance). Past Hstory - he had been wounded n the back and sde n November 1917 by shrapnel. A.T.S. njected at Advanced Dress* ng Staton and another dose at the C.C.S. whence he was evacuated to No. General Hosptal at the base. On Admsson to ward. Blateral cv>zu.o spasms of both arms and trunk; these are sad to have started at 2 a.m. of to-day wth pan n the back and legs and back of neck especally. On examnaton - there was no rgdty of neck muscles. Ho Kerng's sgn. No spasm of the Masseter Muscle. Knee jerks ++ No ankle clonus. v\ The hands were held n poston of tetany (carpo-pedal pasm). He told me that he had vomted some "nasty stuff" whch was very btter. The tongue was furred.

47 33. HERVOUS SYMPTOMS (Contnued) Jerks much less* Dd not occur durng sleep. No nystagmus. Knee jerks -f-f Autosuggeston and hypnoss were then tred by me wth success. IE Jerks ceased. Headache and pans n the lmbs Tongue cleaner. Pans practcally gone and the man professed to be anxous to return to hs Unt. However, t was thought advsable to evacuate hm to the base.

48 34. TREATMENT. The oases were grouped roughly for purposes of treatment nto two - mld and severe - wth chest complcatons. Dealng wth a large number of oases, t was necessary to make the treatment of a routne nature. On admsson the mld oases were gven Cal. Gr. IV. Mag. Sulpho Mane, and a mxture contanng Sod. Sal. and Antpyrn. The frst nght they were gven Pulv. Ipecac. Co. (Jr. X. If there was stll a cough, an expectorant mxture and tonc treatment was gven before they were sent to lght duty. Lght duty was done at the G.C.S. f possble, or the men, on beng dscharged to duty, were gven a note suggestng that they should be gven three days' lght duty. The more severe easels were treated wth the undermentoned mxture of* Ammon. Garb, and Stroph,anth s, and stmulants freely gven when necessary. Depresson was marked n most cases and they reacted well to brandy. Several cases were gven rectal njecton of 5$ Sod. Bc. soluton, wth the vew of combatng an acute toxaema whch mght cause death from myocardal degeneraton. Ths was thought advsable n that the bronchopneumona was not consdered suffcent to cause death from pure mechancal blockage of lung space. Ths condton was confrmed by post-mortem examnaton

49 35, TRSATMEUT (Contnued). n several cases. Prescrptons: Mst. Sod. Sal. c. Antpyrn R. Sod. Saloylas Gr. v Phenazon Gr. v Tr. Hue. Yom. M. v Glycerne M. xv Aq. Chlor. ad. Mst. Ammon. Garb, o. Strophanthus. R, Yn. Ipecac. M. x. Tr. Strophanthus M. v. Ammon. Carb. Gr. v a Potass. lodd. Gr. v. Aq. Chlor. ad Rectal Injecton Sod. Bo. * to To the more toxc cases Sodum Bcarbonate was gven n all feeds and n the vefy severe cases was gven as an enema of "Vvl to the pnt nght and mornng. I dd not thnk t advsable to gve t ntravenously, as I consdered t mght overburden an already tred heart. The patent then retaned as lttle or as much as possble wthout ncreasng the amount of crculatng flud.

50 36. TREATMENT (Contnued). The reason for gvng Sod. Bc. n the frst nstance was because one noted the great frequency of blood and albumen n the urne of these patents. Sod. Bc. has been found of the great est use n the treatment of war nephrts. Chest oases wth delrum and restlessness were gven morphne Gr«-^ and Atropn Gr-ggrj) subcutaneously at nght. Ths acted almost as a charm n some of the cases and they awoke refreshed and nvgorated by -a good nght's sleep. Paraldehyde was tred for sleeplessness, but wthout any real good effect. Several cases presentng an ntense cardac dyspnoea wth restlessness reacted well to large doses of brandy. Brandy was gven every hour for fve doses and then at the sxth hour % * ~^2^y were gven. Ths also seemed to combat sleeplessness and the patent often drfted nto a calm and placd sleep. Ptutrn was tred, but I thnk that f anythng t tended to do harm by gvng the heart more to do. Treatment by qunne I found was qute useless after the tvmar?ar*v_; frst day of fever. ^rom a prophylactc pont of vew^ I have dscussed t at length n another paragraph.^o^^ jv \

51 37. PROPHYLAXIS. There a no queston that durng ta epdemc the prophylactc use of qunne s benefcal n reducng the number -of oases, n dmnshng the dsease and preventng complcatons. Qunne was gven to 40 men of traffc control n doses of Or. (tablet) t.d,s. Although not absolutely preventng the dsease, the men were attacked to a lesser degree and there were no complcatons. Some of the men were able to carry on ther work when t was necessary. I was consulted by an offcer of a Traffc Control re the prophylactc use of qunne, after a few cases had broken out n hs Unt. Hs unt was broken up n detachments n dfferent areas near by. I recommended that 4 gr. of Qunne Sulphate be gven n doses of Gr. mornng and nght to the headquarters unt. At the headquarters of ths unt there were 40 men of whom there were 3 who ntroduced the dsease. These men were eventually evacuated through the clearng staton to the base. After ths, two men contracted t and were evacuated to hosptal and were under my care. Qunne was then gvenwth the followng result:

52 38. PROPHYLAXIS (Contnued). About sx men were seedy and were gven qunne, also the rest of the unt. Ho more cases occurred. The other detachments had the followng cases:- At Roguemason 15 men Every man contracted nfluenza. Not gven qunne. Several evacuated to hosptal. Hune 12 men Bad attack wth chest troubles; 1 case developed pneumona; 3 evacuated to hosptal. BpJ; gven qunne. Grouy en Artos 8 men 0 cases. 10 evacuated to hosptal. 2 men evacuated to the base through a C.G.S., wth complcatons. Qunne not gven. The followng experence of a colleague of mne s nterestng n supportng the vew that qunne s of use as a prophylactc, A certan S»H.A«Battery started wth nfluenza n ts centre secton, about IE cases among 80 men. Ther offcer went and slept wth them to mantan solaton. He went down wth t n two days' tme. Ths offcer dd not take qunne. The other sx

53 39. PROPHYLAXIS (Contnued). offcers took qunne (4 gr) and escaped the dsease. Of the mess servants, 3 n number, 2 took qunne and the other dd not; the latter was the only case. There were three other sectons - rght, left and moble - each of 60 men. The rght secton (of about 60 men) took gr.. of qunne only a day. The moble and left went down farly quckly. The rght secton went down much later - roughly ten days later - wth very few cases and those comparatvely lght. It then broke out n the M.G.C. (Machne Gunners Coy.), owng to a sergeant of the moble secton aforementoned gong over to teach the Transport secton of the Machne Gunners. Practcally every man of the transport went down heavly. Of the remander, A. and B. sectons (about 30 men n each) were lodged n a chateau. It then started n A. secton. B. secton were put on qunne, gr. v. daly, wth the result that only a very few cases occurred n B. secton, but t ran the usual course through A. secton. A.secton had not been gven qunne. All the offcers of all sectons of the M.G.C. took qunne and escaped the dsease.

54 40. ANOMALOUS CASKS. Enlargement of the Thyrod followng nfluenza Pte. C. let Wlts B. Roadman n cvl lfe. Hstory of p're a llne ss. Pans and headache about one month ago. The offcer sad he had a slght attack of nfluenza. He reported sck wth ths and was gven medcne and lght duty. He states that up to the present tme had not "felt hmself" so reported sojc on the and was dagnosed by the Feld Ambulance as Deblty and sent down to the C.C.S. On admsson to C.C.S. Complans of weakness of the legs and feelng "shaky", and attacks of palptaton. Sweatng. On examnaton - anaemc appearance. Pulse feeble BxophthalmoB presdnt; fulness of the thyrod. Yon Graefe's sgn present. Pne tremor of the fngers. Tongue somewhat tremulous. Ho bruts were heard n cardac regon, patent very depressed MOTE: Patent sad that he had never had tremors or palptaton before the last llness. He had E-E/a years' servce of whch 20 months were spent n France. I am nclned to thnk that none of hs symptoms were due to shell shock and he had not been n hosptal before. It mght be dffcult to say that ths enlargement of the thyrod was due to the nfluenza bacllus, but as I have had 3

55 41. AKOMALOUS CASES (Contnued). other oases of marked enlargement of the thyrod n cases who were undoubtedly nfluenzal n orgn, and as ths case had occurr ed durng the epdemc, I thought t worth whle recordng.

56 42, EPIDEMIC IN MY Om UBIT. Durng the early part of May, 1918, there was an epdemc amongst the offcers and personnel of my own unt. It was of a mld nature and the men were perfectly well n about 5 to 7 days«there were ho after-effects. The symptoms presented were those not unlke that of a mld nfluenzal nfecton. Is t possble, n vew of the great epdemc that s now dmnshng n volence, that ths slght epdemc was the herald of the greater one? It s concevable that the nfecton of both was due to the same organsm or organsms and that as the dsease progressed the nfecton became more vrulent. In ths unt roughly consstng of 112 offcers and men, 30 cases occurred, 28 amongst the men and 2 amongst the offcers. The onset was n all cases qute sudden and often the tme of feelng ll was known. All cases complaned of ntense headache, pans all over, a rawness down the sternum, slght sore throat. The temperature was never hgher than 103 and generally about 101. Several men complaned of feelng shvery at the onset, although defnte rgors occurred only n 3 cases. All cases complaned df feelng lmp and ntense lasstude for the frst few days; ths gradually passed off. The fever was of three days' duraton n every case and came down to normal on the fourth day.

57 43, DEMIC IS m OM UHIT (Contnued). There was slght oough wth very lttle tenacous sputum. T> l\ \/wl\ «U( t Ths occurred n every case. HystagAsLa occurred n about ten cases. There was no enlargement of the spleen noted* There were no spots. Herpes labals occurred n three cases, two among some bat$en who occupy the same tent. The ncubaton perod seems to have been two days from the tme these two batmen were nfected. Ths epdemc has much n common wth the mlder cases of the present epdemc. The bacterologcal evdence also ponts to there beng some connecton. Pfeffer's bacll were seen from a drect smear n tone case, and several oases presented a growth of Gr am (~> bacll whch mght possbly have been Pfeffer. It was some days before we realsed that we mght be dealng wth cases of pure nfluenza and not cases of P.U.O. (Pyrexa of unknown orgn or potental trench fevers). Eowever, there was also dffculty n gettng the organsms found to grow and the nfluenza bacllus s not one of the easest to culture, except under the most favourable condtons.

58 44. EPIDEMIC IN m OWN UNIT (Contnued). Clncally these cases were nfluenza and not at all lke those of the trench fever type. I have added two cases to llustrate ths type. It wll be notced that respratory symptoms were present n the form»> >t of cough and the rawness of the sternum, showng a "trachets". There are, as a rule, no respratory complcatons n the ordn ary P.U.O. or trench fever cases. ILLUSTRATIVE CASES OF EPIDEMIC IN MY OWN UNIT Padre T Taken ll qute suddenly at a.m. Complanng then of slght sore throat and rawness of the chest. Felt exhausted and tred. Shverng. Then headache and backache. Pans n the lmbs later. T p«so Pnk Eye - slght "nystagmus. No spots. Spleen not enlarged. Tongue furred «T. 99. Headache better. Eyes stll ache. Slght mystagmus present. Throat easer. Pans n the lmbs easer. Tongue cleaner. We^st swab taken T Feels better except for slght backache and an rrtable cough.

59 45, ILLUSTRATIVE CASES OP EPIDEMIC US M* OWH UNIT (Contnued) Feels better. Voce stll htfsky. Herpes labals Much better. Bacterologcal examnaton - Gram + coccus ^*v>j_v»tsvoevl/ Gram - coccus? Catarrhals '" - bacll?? Captan B.T.B.. R.A.M.C Temp Headache, feelng lmp, tendency to shver, rrtable cough. Tongue furred. Dovers Powder and Asprn Gr.x. Gr.x, Temp. 99. Headache, pans n the lmbs. Cough. Sputum of tough consstency and tendency to nummulate Temp. 99. Slght headache - pans n the lmbs Peelng slack. Cough. Obscure aches. T^ a Better. Baot. Exam;- Sputum. Gram + coccus " - cocc? Catarhhals. 11 ~ bacll??

60 46, AETIOLOGY AffD PAmOLOGY. Doubts have arsen as to the epdemc beng caused by the nfluenza or Pfeffer's bacllus. Artcles have appeared n the Lancet and Brtsh Medcal Journal from tme to tme durng the epdemc statng that the wrters had not been able to fnd the bacllus. However,there can be no queston that n conjuncton wth the pneumococous, the nfluenza bacllus was the predomnant factor. In every case we nvestgated durng the heght of the epdemc, ether sputum or West swabs of the nasopharynx, the pneumococous was nvarably found ether wth Pfeffer's bacllus or not. It has been suggested that the pneumo-coccus outgrows the nfluenaa bacllus after 3-4 days, and ths was our experence n the great majorty of the cases we nvestgated. Smears from the larger bronch taken post mortem show also pneumo-goce n conjuncton wth pfeffer. Blood cultures were nvarably dsappontng, no growth as a rule beng obtaned. Durng the epdemc n my own unt, n several cases I was able to get sputum and from ths we were able to demonstrate a Gram negatve bacllus, whch morphologcally resembled Pfeffer's bacllus. Unfortunately we were unable to grow t and confrm t by culture.

61 47, AE2PIOLOGY ATOPATKOLOGY (Contnued) However, n the lght of thngs that have taken place later, I am convnced that ths organsm (Gram negatve bacllus) was Pfeffer, and that the seres of relatvely slght local epdemcs, or shall we say endemcs? - were the forerunners of the great pandemc whch was to scourge the armes later. The fgures I have gven are only those of whom came under my care for one month. I was unable to get further statstcs of the next two months owng to the mltary stuaton. However, I performed a number of autopses durng the later part of the epdemc, and propose to roughly ndcate the changes I perceved. Thyro d; Enlargement of the thyrod blaterally occrred n 5 of my oases, one of whch was very marked, and a secton was cut whch showed on mcroscopc examnaton acute nflammatory change. Lungs: The essental condton found was that of a Bronchopneumona whch vared accordng to the length of the dsease. Some cases presented large areas of consoldaton, whch almost suggested a lobar pneumona, bjt on further nspecton typcal broncho-pneumona patches could be made out. In three of my cases, there was a relatvely small area of lung nvolved, and death n those cases must have been due to an extreme toxaema and not due to any mechancal blockage of the lung tssue.

62 48, AETIOLOGY AKD PATHOLOGY (Contnued). Fresh pleursy and pleural adhesons were the rule. Two of ray oases showed marked daphragmatc pleursy, whch durng lfe caused ntense dstress and pan to the patents. Where the consoldaton was marked, areas of early necross were found. Oedema of the lungs was nfrequent. Emphysema of a compensatory nature was also found. In one case a small nterlobar empyema was present. Pleural effusons were rare and only occurred n two of my cases. Practcally every change could be notced n the lungs; the small bronch and broncholes were full of frothy and not nfrequently muco-purulent or purulent flud, areas of congeston, mostly at the bases, areas of red hepatsaton gong on to grey hepatsaton or even necross. Heart: Greater or lesser enlargement of the heart was common. Cloudy swellng or fatty change of the heart muscle was constant. The heart was generally found n the poston of systole (left). Percardts occurred wth effuson n 2 cases. Prom one we recovered the pneumococcus by drect smear. A farly constant feature was the presence of a few small fresh percardal adhesons on the rght aurcular appendage. Endocardts occurred n one case (Sgt. W.).