Читать книгу Studies on Epidemic Influenza: Comprising Clinical and Laboratory Investigations - University of Pittsburgh. School of Medicine - Страница 25

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In giving a prognosis of influenza one has to take into consideration the peculiar manifestations of the disease, especially the possible and sudden changes which are liable to take place in the lungs. The points which lead one to feel that the outlook is grave occur in about the following order, which is also about the order of the severity of the symptoms. First, cyanosis. This usually appeared quite early and was considered a forerunner of definite lung infection. It may have been a symptom only of the “wet lung,” to which reference has been made, but it was usually followed with definitely recognized pathology in the chest, and it immediately made the outlook unfavorable. Second, continuation of elevated temperature. If the temperature fell to normal in three or four days, the outlook was, of course, good; but if it went up again, or if the temperature did not fall in that time, the chances were that there was a lung involvement, even though the chest signs were negative or only those of an acute bronchitis. Strange to say, however, when definite chest signs were once recognized, the height of the temperature or the continuation of fever was not so important a prognostic factor. Third, increase in pulse rate. The pulse, as was noted before, was unusually slow, even though the patient seemed desperately ill; when, however, it began to increase in rate the condition was usually very grave. Fourth, the extent of lung involvement. This was of very little prognostic value. Both lower lobes might be solid, and yet if there was no cyanosis and the pulse and respirations were satisfactory, the outlook was rather good. On the other hand, there might be the slightest involvement of the lung, and if the pulse were rapid and cyanosis present the outlook was grave. Fifth, depression and stupor, or loss of so-called “morale.” If the patient remained clear in his mind, bright and hopeful, no difference how extensive the involvement or how grave the symptoms, the prospect of recovery was better. This is, of course, not peculiar to influenza, but it seemed particularly striking during the epidemic. Sixth, a gradually rising rate in respiration, which often was not more than two per minute per day, if progressive, even in the absence of other untoward signs, conveyed a serious prognosis.

Our mortality among the civilians in comparison with the soldiers was exceedingly high. The first cases seen by us were among the soldier patients sent to the hospital. These were as fine a lot of healthy young men as one can well imagine. They came to the hospital comparatively early in the infection. After the first week it appeared as though our experience would be entirely different from those in other localities, for we had very few deaths. In another week our mortality began to rise, but never as high as among the civilians, as will be seen by the following figures.

Of the 153 soldiers 87 were without lung involvement, and of these none died; 66 had lung involvement, and of these 16 died. Mortality among the 153 was 10 per cent. Of the 394 civilians 157 were without lung involvement, and of these 1 died; 237 had lung involvement, or some other complication, and of these 93 died. Mortality among the 394 was 23.6 per cent.

It will be seen that the mortality in the civilians was more than twice as high as in the soldiers. It has already been mentioned that the soldiers were ordered to the hospital promptly. The civilian patients, on the other hand, were later in coming to the hospital, some of them appearing when they had already developed serious complications. Another factor in determining the mortality were the ages of the patients. The soldiers ranged from 18 to 34 years, with an average of 20 years. The civilians ranged from 6 months to 73 years, with an average of 30 years. Generally speaking, the greater the age the higher was the mortality.

A third factor which should be considered in determining the actual mortality is the result of later complications and sequelæ. The figures as given are those of 547 patients, 110 of whom had died in the Mercy Hospital and 437 of whom had been discharged therefrom between September 22 and November 30, 1918, the length of the quarantine. Those who were discharged had been up and about for a week or 10 days before leaving the hospital. From our experience with post-influenzal patients admitted to the Mercy Hospital since November 30, we are of the opinion that some of the patients discharged before November 30 as recovered may have later developed sequelæ which might have proved fatal. No follow-up system has been pursued as yet which enables us to speak definitely and statistically of the present condition of those discharged.

This compilation does not readily lend itself to drawing any more specific conclusions, but we cannot desist from expressing our opinion that in the clinical study of this recent epidemic we find very little that may not have been observed by clinicians in previous epidemics.