│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.
In two instances slight hemorrhages were observed into the conjunctival
tissues. In each case they were unilateral and occupied the tissues
contiguous to the inner canthus. In one case there was well-marked
icterus with yellow coloration of the scleræ and skin. In this case the
icterus was associated with degenerative changes in the liver, there
being no recognizable obstruction to the bile passages. The icterus had
come on quite acutely and without any special clinical manifestations.
In the epidemic of 1890 jaundice was present in a considerable number of
cases (Medical Record, 1890, xxxvii, 473). Cole made similar
observations in the epidemic of influenza amongst the Canadian soldiers.
Œdema of the skin was not met with in any of our cases. This point is
worthy of comment, inasmuch as some authors have been impressed with the
serious damage taking place in the kidney and the resulting incapacity
of these organs. Although, as we shall point out later, the kidney
tissues in these cases showed a decided toxic degeneration, there was no
evidence that a glomerular damage of serious degree ever occurred. The
urinary excretion, as is pointed out in a report by Dr. Zeedick, varies
considerably with the intensity of the disease. It is unusual to find
derangement of kidney function to a degree to reflect seriously upon the
general bodily state. At least this has been our experience in the
present epidemic. Even where subsequently we were able to demonstrate a
considerable tubular degeneration in the cortex of the kidney the change
in the kidney function was not of sufficient magnitude to lead to a
water-retention to be recognized in an anasarca. I wish to distinguish
clearly at this point the difference in finding an œdema in certain
involved tissue structures in various parts of the body and arising
through an inflammatory reaction due to the presence of peculiar focal
irritation, as compared with the accumulation of fluid in many and
irregular situations as it occurs through retention and faulty excretion
by the kidneys. Various organs as we have found—as, for instance, the
lung, heart and liver—showed a condition of œdema which was not to be
reconciled with an inadequate circulation because of a cardiac or renal
incompetency. These œdemas, which we will discuss later, are local and
are the result of damaging influences inducted in and upon the tissues
where they are found.
_Muscle_
In all of our cases we have been struck with the excellent physique of
the individuals succumbing to this epidemic. All were youths in the best
of health, of good muscular build and strong bony frame-work.
Post-mortem rigidity set in fairly rapidly after death. Where this
rigidity had “set” for six or more hours it required much force to
change the position of the muscles. The voluntary muscles of the thorax
and abdomen were always carefully observed, and in a number of instances
the muscles of the thigh were also examined. It was not possible
routinely to dissect the muscles of the extremities, so that we are
unable to give an accurate account of the occurrence of degenerations in
these structures. We have, however, observed the reactions taking place
in the pectorals, psoas and muscles of the abdominal parietes. Changes
were observed with greatest frequency in the recti of the abdomen.
Degeneration occurred in these muscles in 14 instances, while the same
tissues suffered rupture, in part or completely with hemorrhage, in six
instances. It was not uncommon to find marked degeneration in the lower
segment of the rectus muscle on one side, while degeneration and
hemorrhage had occurred in its fellow on the opposite side. In four
cases rupture of the entire belly of the muscle had taken place, so that
a considerable space had occurred between the broken ends and a large
clot of blood filled the intervening space. This degeneration, which was
seen only in the voluntary muscles, was quite interesting and in its
milder degrees was rather difficult to detect. All gradations of loss of
muscle color were seen. In some instances the muscle simply seemed to
have lost its meaty lustre, while again in the more severe instances the
muscle color had changed from the bright red to an insipid yellow or
clay color. The most marked degeneration occurred in the midportions,
while the ends of the muscle masses at the points of attachment were
less involved. Complete rupture of the rectus always occurred in the
lowermost segment, a short distance above the insertion into the pubic
bone. At times the distribution of the degeneration within the muscle
was quite patchy, and irregular islands of yellow about 2 cm. in
diameter were splashed through the muscle masses, which in themselves
were paler than normal. Where the muscle degeneration was advanced the
tissue was soft and at times even buttery. It resembled the character of
the degeneration observed in typhoid fever, although I have no
recollection amongst many enteric cases of having seen the degeneration
of the muscle occur so acutely. Recklinghausen claimed that these
hemorrhages were most unusual in influenza. This is contrary to our
findings.
Degenerations of a similar kind as those of the abdominal recti were
found in both pectorals. In the chest region, however, the degeneration
was less frequent and less severe. We observed it only twice, and in
neither instance had the degeneration led to a rupture and hemorrhage of
the muscle bundles. Kuskow observed a single case of degeneration and
hemorrhage of the pectoral muscles. In the psoas muscle we observed
degeneration on two occasions, in one of which the lesion was associated
with a partial separation of the muscle fibers and hemorrhages into its
substance. In one case clinically, but not coming to autopsy, a lesion,
which from its character we presume to have been a degeneration,
occurred in the sterno-mastoid, being accompanied by hemorrhage and the
development of a firm clot the size of a hazel nut. In the subsequent
history of this case the lesion passed through an aseptic process of
organization with contracture so that the patient has recently been
developing a “wryneck.” Kohts in 1890 reported the finding of muscle
degeneration and abscesses in the arm. The condition arose as a late
complication of influenza.
From our experience at the autopsy table in observing the relative
frequency with which muscle degeneration occurs in the severe cases of
epidemic influenza, we feel convinced that numerous cases which recover
pass undiagnosed of this condition. Furthermore we have evidence, as
illustrated in a case observed by Dr. McMeans, wherein a lesion which
occurred in the gluteal muscles was followed by a localizing infection
at this site that these muscle degenerations and hemorrhages may have
serious consequences. There are a number of instances in which
post-influenzal complications of the nature of deep-seated abscesses of
the extremities, thorax, and abdomen may have their explanation for the
localization in a primary muscle damage accompanied by hemorrhage and
followed by an infection of variable type. Cole also comments upon the
development of abscess in the deep muscles where degeneration had taken
place. In illustrating some of our findings to Dr. J. Anderson he
immediately recognized such a condition in the pectoral muscles of a
patient in which he was unable to arrive at a conclusion of the
pathological events which had taken place. It is one of the noteworthy
features in this disease that the voluntary muscles of certain regions
are apt to suffer severe damage, while the heart and the various
unstriped muscular tissues are little if at all affected by a similar
process. It would be interesting to know whether the lack of response
and the delayed functional recovery on the part of the muscles of the
extremities in so many patients who have suffered influenza is the
result of the damaging influence of a peculiar intoxication present in
this disease. One of the features in influenza is the prostration of the
patient, and with it there is definite muscular weakness. We have been
prone to lay the responsibility of this state entirely at the door of
the nervous tissues. Here, however, we are able to offer evidence that
quite aside from the lesions arising in the nervous tissue, there is
definite muscle damage which, as we shall again discuss when describing
the microscopic features, incapacitates even to the point of complete
destruction the muscle elements in various fields of the body. Before,
however, being able to state that the muscular weakness of the
extremities is the result of such damage by toxins it is necessary to
obtain more definite information regarding the frequency with which
these degenerations occur in the limbs. In our own material we are
unable to discuss the matter with adequate figures. We are, however,
impressed with the changes observed in the muscles which were available
to us. Naturally, too, a certain number of muscle degenerations have
escaped our detection because of our unfamiliarity with the mildest
grades. In fact, we have already discovered in our microscopic studies
that certain cases, which in the macroscopic had escaped us, showed
well-marked lesions under the microscope.