Influenza

Annual Report of the Secretary of the Navy, 1919 -- Miscellaneous Reports.


Section 1 - Section 2 - Section 3


INFLUENZA STATISTICS, ENTIRE NAVY.

The following tables contain statistics for the entire Navy:

Table No. 8 shows admissions and annual admission rates per 1,000 of complement by weeks, for influenza, pneumonia (all forms), bronchitis and all these causes combined, for the entire Navy for the whole calendar year 1918.

Table No. 9 shows admissions and annual admission rates per 1,000 of complement by weeks, calendar year, 1918, for influenza, pneumonia (all forms), bronchitis, and these causes combined, for the forces of the United States Navy ashore in the United States.

Table No. 10 shows admissions and annual admission rates per 1,000 of complement by weeks, calendar year, 1918, for influenza, pneumonia (all forms), bronchitis, and these causes combined, for the forces of the United States Navy afloat and expeditionary forces, including marines and expeditionary forces in the Navy in Europe. It has not been possible to secure accurate complement figures separately for the forces afloat and the naval or marine corps forces ashore in Europe.

Table No. 11 shjows deaths and annual death rates per 1,000 of complement by weeks, calendar year 1918, for influenza (including influenzal pneumonia) and pneumonia (all other forms) for the entire Navy.

Table No. 12 shows deaths and annual death rates per 1,000 of complement by weeks, calendar year 1918, for influenza (including influenzal pneumonia and pneumonia (all other forms) for the United States naval forces ashore in the United States.

Table No. 13 shows deaths and annual death rates per 1,000 of complement by weeks, calendar year 1918, for influenza (including influenzal pneumonia) and pneumonia (all other forms) for the United States naval forces afloat and the expeditionary forces of the Navy, including marines, combined. It has not been possible to secure accurate complement figures separately for the forces afloat and naval or Marine Corps forces ashore in Europe.

Chart No. 15 shows the incidence and prevalence of influenza and death rates by weeks in the Navy during the whole calendar year 1918. As indicated, the death rate from influenza (including influenzal pneumonia), expressed in terms of an annual rate per 1,000 of complement, did not rise above 1 in any week until the week ending

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September 6, when it was 2 for the force ashore. The curves indicating admission rates show clearly the prevalence of influenza in the spring months not only among the naval forces afloat and in Europe but also among those in the United States. Diminished prevalence among all forces in July and August is very noticeable.

Image of CHART 15.--Logarithmic scale. United States Navy: Annual admission rates and annual death rates per 1,000 of complement, by weeks, calendar year 1918; influenza, including influenzal pneumonia.
CHART 15.--Logarithmic scale. United States Navy: Annual admission rates and annual death rates per 1,000 of complement, by weeks, calendar year 1918; influenza, including influenzal pneumonia.

Chart No. 16 shows annual death rates per 1,000 of complement by weeks, calendar year 1918, for pneumonia (all forms including influenzal pneumonia) for the entire Navy and separately for the forces ashore in the United States and all other forces, afloat, ashore at foreign stations, and expeditionary forces. While the death rate from influenza did not exceed 1 per 1,000 (annual rate) for any week prior to September 1, as indicated by chart No. 15, the combined rates for influenza and pneumonia (all forms) exceeded this figure nearly every week during January, February, March, April, and May, after which the combined rate, entire Navy, did not exceed this figure until the week ending September 7. Even for the forces ashore in the United States the rate for influenza alone did not exceed 1 per 1,000 until the latter date, although the all-pneumonia rate was occasionally higher than 1 during June, July, and August.

It is very likely that at least some of the deaths from pneumonia in cases where influenza was not considered in diagnosis during

--2441--

Image of Chart 16.--Logarithmic scale. United States Navy: Annual death rates per 1,000 of complement, by weeks, calendar year 1918; pneumonia, all forms, including influenzal pneumonia.
Chart 16.--Logarithmic scale. United States Navy: Annual death rates per 1,000 of complement, by weeks, calendar year 1918; pneumonia, all forms, including influenzal pneumonia.

--2442--

January, February, March, and April were primarily due to influenza, and that the outbreaks of this disease which occurred in the late winter and spring were by no means so benign as the figures for influenza now obtainable would indicate.

Table No. 14 shows the distribution of influenza cases and specific admission rates per 1,000 living, according to age groups, enlisted personnel of the Navy, by months, during the period September 1 to December 31, 1918.

Table No. 15 contains similar date for pneumonia (all forms).

Image of Chart 17.--Specific admission rates and specific death rates per 1,000 living, for influenza, including influenzal pneumonia, and for pneumonia (all forms other than influenzal pneumonia), according to age groups, enlisted personnel of the Navy, September 1 to December 31, 1918.
Chart 17.--Specific admission rates and specific death rates per 1,000 living, for influenza, including influenzal pneumonia, and for pneumonia (all forms other than influenzal pneumonia), according to age groups, enlisted personnel of the Navy, September 1 to December 31, 1918.

Table No. 16 shows the distribution of deaths from influenza, including influenzal penumonia, among age groups and specific death rates per 1,000 living, by months, enlisted personnel of the Navy, during the period September 1 to December 31, 1918.

Table No. 17 shows deaths and specific death rates per 1,000 living, for pneumonia (all forms other than influenzal pneumonia), by months, according to age groups, enlisted personnel of the Navy, during the period September 1 to December 31, 1918.

Table No. 18 shows case-fatality rates for influenza, including influenzal pneumonia and pneumonia (all other forms), according to age groups.

Admission rates and death rates for several age groups, enlisted personnel, period September 1 to December 31, 1918, are shown in chart No. 17.

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TABLE No. 8.--Entire Navy: Admissions and annual admission rates per 1,000 by weeks, 1918, influenza, pneumonia (all forms), bronchitis.

Week. Comple-
ment.
Influenza. Pneumonia
(all forms).
Bronchitis. Total
Case. Rate. Case. Rate. Case. Rate. Case. Rate.
Jan. 5 329,878 502 79.04 105 16.12 276 43.16 883 138.84
Jan. 12 336,567 634 97.76 159 24.44 336 51.48 1,129 174.20
Jan. 19 343,256 607 91.52 174 26.00 299 45.24 1,080 163.28
Jan. 26 349,945 680 100.88 146 21.32 273 40.56 1,099 163.28
Feb. 2 356,634 648 94.12 135 19.24 312 45.24 1,095 159.64
Feb. 9 363,323 903 128.96 136 19.24 259 36.92 1,298 185.64
Feb. 16 370,012 815 114.40 112 15.60 319 44.72 1,246 174.72
Feb. 23 376,701 968 133.12 123 16.64 232 31.72 1,323 182.52
Mar. 2 383,390 1,473 199.68 193 26.00 259 34.84 1,925 260.52
Mar. 9 390,079 1,402 186.68 215 28.60 282 37.44 1,899 252.72
Mar. 16 396,768 1,465 191.88 211 27.56 231 30.16 1,907 249.60
Mar. 23 403,457 1,307 167.96 162 20.80 197 24.96 1,666 214.24
Mar. 30 410,146 1,216 153.92 119 15.08 199 24.96 1,534 194.48
Apr. 6 416,835 1,290 160.68 138 17.16 207 25.48 1,635 203.84
Apr. 13 423,524 1,111 136.24 236 28.60 198 23.92 1,545 189.28
Apr. 20 430,213 1,044 122.20 116 13.52 153 18.20 1,283 154.96
Apr. 27 436,902 649 76.96 93 10.92 173 20.28 915 108.68
May 4 443,591 917 107.12 83 9.36 158 18.20 1,158 135.72
May 11 450,280 848 97.76 84 9.36 160 18.20 1,092 125.84
May 18 456,969 675 76.44 60 6.76 164 18.20 899 101.92
May 25 463,658 531 59.28 54 5.72 166 18.20 751 83.72
June 1 470,347 583 63.96 47 4.58 130 14.04 760 83.72
June 8 477,036 549 59.77 49 5.20 124 13.00 722 78.52
June 15 483,725 640 68.64 35 3.64 140 14.56 815 87.36
June 22 490,414 575 60.84 36 3.64 143 15.08 754 79.56
June 29 497,103 816 85.28 32 3.12 174 18.20 1,022 106.60
July 6 503,792 773 79.56 39 3.64 133 13.52 945 97.24
July 13 510,481 954 96.72 47 4.68 147 14.56 1,148 116.48
July 20 517,170 720 72.28 50 4.68 150 15.08 920 92.04
July 27 523,859 613 60.84 50 4.68 213 20.80 876 86.84
Aug. 3 530,548 623 60.84 35 3.12 197 19.24 855 83.72
Aug. 10 537,237 468 45.24 57 5.20 171 16.12 696 67.08
Aug. 17 543,926 489 46.28 63 5.72 226 21.32 778 74.36
Aug. 24 550,615 528 49.40 43 3.64 264 24.44 835 78.52
Aug. 31 557,304 762 70.72 53 4.68 246 22.88 1,061 98.80
Sept. 7 563,993 1,314 120.64 70 6.24 268 24.44 1,652 151.84
Sept. 14 570,682 5,568 507.00 153 13.52 358 32.24 6,079 553.80
Sept. 21 577,371 17,233 1,551.68 1,016 91.00 337 30.16 18,586 1,673.88
Sept. 28 584,060 16,117 1,434.68 2,112 187.72 529 46.80 18,758 1,669.72
Oct. 5 590,749 13,800 1,214.72 1,863 163.80 523 45.76 16,186 1,424.28
Oct. 12 597,438 9,041 786.76 1,090 94.64 434 37.44 10,565 919.36
Oct. 19 604,127 6,396 550.16 790 67.60 327 28.08 7,513 646.36
Oct. 26 610,816 4,418 375.96 364 30.68 296 24.96 5,078 432.12
Nov. 2 617,505 3,809 320.32 299 24.96 296 24.44 4,404 370.76
Nov. 9 624,205 2,596 215.80 176 14.56 307 25.48 3,079 256.36
Nov. 16 624,205 2,152 178.88 136 10.92 377 31.20 2,665 221.52
Nov. 23 624,205 1,709 141.96 158 13.00 352 29.12 2,219 184.60
Nov. 30 624,205 1,257 104.52 81 6.24 356 29.64 1,694 140.92
Dec. 7 624,205 1,411 117.52 93 7.28 428 35.36 1,932 160.68
Dec. 14 624,205 1,734 144.04 147 11.96 503 41.60 2,384 198.21
Dec. 21 620,000 1,598 133.64 136 10.92 378 31.20 2,112 176.80
Dec. 28 614,000 1,075 91.00 97 7.80 270 22.36 1,442 121.68
Dec. 29-31 614,000 428 84.18 35 6.10 86 17.08 549 108.58
Total 503,792 120,404 238.99 12,306 24.42 13,736 27.26 146,446 290.63

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TABLE No. 9.--United States Navy forces ashore in the United States Admissions and annual admission rates per 1,000 by weeks, 1918, influenza, pneumonia (all forms), bronchitis.

Week. Comple-
ment.
Influenza. Pneumonia
(all forms).
Bronchitis. Total
Case. Rate. Case. Rate. Case. Rate. Case. Rate.
Jan. 5 106,693 281 136.24 81 39.00 185 89.44 547 265.72
Jan. 12 112,262 361 166.92 121 55.64 236 109.20 718 382.28
Jan. 19 107,978 339 162.76 130 62.40 196 94.12 665 319.80
Jan. 26 104,858 368 182.00 117 57.72 185 91.52 670 331.76
Feb. 2 105,089 364 179.92 102 50.44 223 110.24 689 340.60
Feb. 9 103,168 450 226.72 99 49.40 179 89.96 728 366.60
Feb. 16 100,716 440 226.72 79 40.56 239 123.24 758 391.04
Feb. 23 102,018 441 224.64 90 45.76 165 83.72 696 354.64
Mar. 2 105,232 56- 276.64 144 70.72 169 83.80 873 431.08
Mar. 9 106,648 595 290.16 145 70.72 166 80.60 906 441.48
Mar. 16 111,257 674 314.60 132 61.36 136 63.44 942 439.92
Mar. 23 106,557 591 288.08 99 48.36 128 62.40 818 398.84
Mar. 30 107,821 600 289.12 87 41.60 125 59.80 812 391.56
Apr. 6 110,782 657 307.84 100 46.80 131 61.36 888 416.52
Apr. 13 111,942 616 287.04 196 91.00 115 53.04 927 430.56
Apr. 20 114,400 745 338.52 77 34.84 81 36.40 903 410.28
Apr. 27 118,090 398 175.24 71 31.20 125 54.60 594 261.56
May 4 112,968 377 173.16 51 23.40 84 38.48 512 235.56
May 11 121,246 320 136.76 52 21.84 103 43.68 475 203.32
May 18 122,401 209 88.40 39 16.12 96 40.56 344 146.12
May 25 126,855 216 88.40 33 13.52 102 41.60 351 143.52
June 1 132,434 236 92.56 30 11.44 73 28.60 339 132.60
June 8 139,267 211 78.52 27 9.88 80 29.64 318 118.56
June 15 148,282 240 83.72 16 5.20 100 34.84 356 124.80
June 22 154,248 187 62.92 25 8.32 99 34.28 311 104.52
June 29 159,415 236 76.76 26 8.32 119 38.48 381 123.76
July 6 166,456 295 92.04 28 8.32 82 25.48 405 126.36
July 13 171,215 217 65.52 29 8.32 102 30.68 348 105.56
July 20 175,116 203 59.80 35 9.88 102 30.16 340 100.88
July 27 186,093 157 43.68 32 8.84 149 41.60 338 94.12
Aug. 3 197,643 184 48.36 23 5.72 126 32.76 333 87.36
Aug. 10 206,020 197 49.40 43 10.40 116 29.12 356 89.44
Aug. 17 207,693 206 51.48 50 11.96 159 39.52 415 103.48
Aug. 24 214,019 257 62.40 31 7.28 166 40.04 454 110.24
Aug. 31 216,654 468 112.32 38 8.84 182 43.68 688 164.84
Sept. 7 220,339 869 204.88 44 9.88 188 44.20 1,101 258.48
Sept. 14 234,760 4,458 986.96 117 25.48 248 54.60 4,823 1,068.08
Sept. 21 247,954 14,380 3,015.48 825 172.64 205 42.64 15,410 3,231.28
Sept. 28 255,066 11,851 2,416.96 1,829 370.76 406 82.68 14,086 2,871.44
Oct. 5 254,676 9,776 1,993.68 1,593 325.00 387 78.52 11,7756 2,383.68
Oct. 12 255,421 5,757 1,171.56 878 178.36 295 59.80 6,930 1,410.76
Oct. 19 249,392 3,656 761.80 564 117.52 195 40.56 4,415 920.40
Oct. 26 250,831 2,509 520.00 223 45.76 217 44.72 2,949 611.00
Nov. 2 247,020 2,087 438.88 202 42.12 208 43.68 2,497 525.20
Nov. 9 246,313 1,940 409.24 120 24.96 192 40.04 2,252 475.28
Nov. 16 244,974 1,402 298.48 105 21.84 262 55.12 1,769 375.44
Nov. 23 243,385 1,051 224.12 132 28.08 242 51.48 1,425 304.20
Nov. 30 244,296 789 167.44 63 13.00 241 50.96 1,093 232.44
Dec. 7 245,858 1,052 222.04 66 13.52 317 66.56 1,435 303.16
Dec. 14 238,666 1,154 251.16 120 26.00 337 73.32 1,611 351.00
Dec. 21 239,313 913 197.60 101 21.84 239 51.48 1,253 271.44
Dec. 28 228,427 648 147.16 71 16.12 162 36.40 8881 200.20
Dec. 29-31 218,783 269 148.84 23 12.20 51 28.06 343 190.32
Total 193,818 77,457 399.63 9,554 49.29 9,216 47.54 96,227 496.48

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TABLE No. 10.--United States Navy forces afloat and expeditionary forces (including marines) combined: Admissions and annual admission rates per 1,000 by weeks, 1918, influenza, pneumonia (all forms), bronchitis.

Week. Comple-
ment.
Influenza. Pneumonia
(all forms).
Bronchitis. Total
Case. Rate. Case. Rate. Case. Rate. Case. Rate.
Jan. 5 222,895 221 51.48 24 5.20 91 20.80 336 78.00
Jan. 12 224,305 273 62.92 38 8.84 100 22.88 411 95.16
Jan. 19 235,278 268 58.76 44 9.36 103 22.36 415 91.52
Jan. 26 245,087 312 66.04 29 5.72 88 18.20 429 91.00
Feb. 2 251,545 284 58.24 33 6.76 89 18.20 406 83.72
Feb. 9 260,155 453 90.48 37 7.28 80 15.60 570 113.88
Feb. 16 269,296 375 72.28 33 6.24 80 15.08 488 94.12
Feb. 23 274,683 527 99.32 33 5.72 67 12.48 627 118.56
Mar. 2 278,158 913 170.56 49 8.84 90 16.64 1,052 196.56
Mar. 9 283,431 807 147.68 70 13.00 116 20.80 993 182.00
Mar. 16 285,511 791 144.04 75 13.52 95 17.16 961 174.72
Mar. 23 296,900 716 125.32 63 10.92 69 11.96 848 148.20
Mar. 30 302,325 616 105.56 32 5.20 74 12.48 722 123.76
Apr. 6 306,053 633 107.12 38 6.24 76 12.48 747 126.88
Apr. 13 311,582 495 82.16 40 6.24 83 13.52 618 102.96
Apr. 20 315,813 269 44.20 39 6.24 72 11.44 380 62.40
Apr. 27 318,812 251 40.56 22 3.12 48 7.80 321 52.00
May 4 330,623 540 86.32 32 4.68 74 11.44 646 101.40
May 11 329,034 528 85.28 32 4.68 57 8.84 617 97.24
May 18 334,568 466 72.28 21 3.12 68 10.40 555 85.80
May 25 336,803 315 48.36 21 3.12 64 9.88 400 61.26
June 1 337,913 347 53.04 17 2.60 57 8.32 421 64.48
June 8 337,769 338 52.00 22 3.12 44 6.76 404 61.88
June 15 335,443 400 61.88 19 2.60 40 5.72 459 70.72
June 22 336,166 388 59.80 11 1.56 44 6.76 443 68.12
June 29 337,688 530 81.12 6 .88 55 8.32 591 91.00
July 6 337,336 478 73.32 11 1.56 51 7.80 540 83.20
July 13 339,266 737 112.84 18 2.60 45 6.76 800 122.20
July 20 342,054 517 78.52 15 2.08 48 7.28 580 87.88
July 27 337,766 456 70.20 18 2.60 64 9.36 538 82.68
Aug. 3 332,905 439 68.12 12 1.56 71 10.92 522 81.12
Aug. 10 331,217 271 42.12 14 2.08 55 8.32 340 53.04
Aug. 17 336,233 283 43.16 13 1.56 67 9.88 363 55.64
Aug. 24 336,596 271 41.60 12 1.56 98 15.08 387 59.28
Aug. 31 340,650 294 44.72 15 2.08 64 9.36 373 56.68
Sept. 7 343,654 445 67.08 26 3.64 80 11.96 551 83.20
Sept. 14 335,922 1,110 171.60 36 5.20 110 16.64 1,256 193.86
Sept. 21 329,417 2,853 450.32 191 30.16 132 20.80 3,176 501.28
Sept. 28 328,994 4,266 673.92 283 44.72 123 19.24 4,672 738.40
Oct. 5 336,073 4,024 622.44 270 41.60 136 20.80 4,430 685.36
Oct. 12 342,017 3,284 499.20 212 31.72 139 20.80 3,635 552.24
Oct. 19 354,735 2,740 401.44 226 32.76 132 19.24 3,098 453.96
Oct. 26 359,985 1,909 275.60 141 20.28 79 10.92 2,129 307.32
Nov. 2 370,485 1,722 241.28 97 135.52 88 11.96 1,907 267.28
Nov. 9 377,892 656 89.96 56 7.28 115 15.60 827 113.36
Nov. 16 379,231 750 102.44 41 5.20 115 15.60 906 123.76
Nov. 23 380,820 658 89.44 26 3.12 110 14.56 794 108.16
Nov. 30 379,909 468 63.96 18 2.08 115 15.60 601 82.16
Dec. 7 378,347 359 48.88 27 3.64 111 15.08 497 68.12
Dec. 14 385,539 580 78.00 27 3.64 166 22.36 773 104.00
Dec. 21 380,687 685 93.08 35 4.68 139 18.72 859 117.00
Dec. 28 385,573 427 57.20 16 2.08 108 14.56 551 74.36
Dec. 29-31 395,217 159 48.80 12 3.66 35 9.76 206 63.44
Total 309,974 42,947 138.55 2,752 8.87 4,520 14.60 50,219 162.01

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TABLE No. 11.--Entire Navy: Deaths and annual death rates per 1,000 by weeks, 1918, influenza and pneumonia (all forms).

Week. Comple-
ment.
Influenza. Pneumonia
(all forms).
Total
Case. Rate. Case. Rate. Case. Rate.
Jan. 5 329,878 ------ ------ 6 0.93 6 0.93
Jan. 12 336,567 1 0.15 18 2.75 19 2.91
Jan. 19 343,256 ------ ------ 21 3.17 21 3.17
Jan. 26 349,945 ------ ------ 13 1.92 13 1.92
Feb. 2 356,634 1 .14 25 3.64 26 3.74
Feb. 9 363,323 ------ ------ 18 2.54 18 2.54
Feb. 16 370,012 ------ ------ 17 2.34 17 2.34
Feb. 23 376,701 ------ ------ 22 3.01 22 3.01
Mar. 2 383,390 1 .13 22 2.96 23 3.06
Mar. 9 390,079 ------ ------ 37 4.88 37 4.88
Mar. 16 396,768 1 .13 50 6.55 51 6.65
Mar. 23 403,457 ------ ------ 40 5.14 40 5.14
Mar. 30 410,146 ------ ------ 39 4.94 39 4.94
Apr. 6 416,835 1 .11 23 2.86 24 2.96
Apr. 13 423,524 ------ ------ 19 2.28 19 2.28
Apr. 20 430,213 2 .23 20 2.39 22 2.65
Apr. 27 436,902 1 .11 22 2.60 23 2.70
May 4 443,951 ------ ------ 9 1.04 9 1.04
May 11 450,280 2 .22 11 1.24 13 1.45
May 18 456,969 ------ ------ 13 1.45 13 1.45
May 25 463,658 1 .10 5 .52 6 .62
June 1 470,347 ------ ------ 7 .72 7 .72
June 8 477,036 1 .10 3 .32 4 .43
June 15 483,725 2 .20 1 .10 3 .32
June 22 490,414 ------ ------ 6 .62 6 .62
June 29 497,103 1 .10 2 .20 3 .31
July 6 503,792 1 .09 2 .20 3 .30
July 13 510,481 ------ ------ 3 .30 3 .30
July 20 517,170 ------ ------ 8 .72 8 .72
July 27 523,859 2 .19 3 .29 5 .49
Aug. 3 530,548 2 .19 1 .09 3 .29
Aug. 10 537,237 ------ ------ 5 .48 5 .48
Aug. 17 543,926 ------ ------ 8 .72 8 .72
Aug. 24 550,615 1 .09 4 .37 5 .46
Aug. 31 557,304 1 .09 3 .27 4 .36
Sept. 7 563,993 9 .78 4 .36 13 1.19
Sept. 14 570,682 38 3.43 12 1.09 50 4.52
Sept. 21 577,371 266 23.92 14 1.24 280 24.96
Sept. 28 584,060 989 87.88 64 5.20 1,053 93.60
Oct. 5 590,749 802 70.20 43 3.74 845 74.36
Oct. 12 597,438 655 56.68 26 2.23 681 58.76
Oct. 19 604,127 478 41.08 21 1.76 499 42.64
Oct. 26 610,816 248 20.80 13 1.09 261 21.84
Nov. 2 617,505 170 14.08 2 .16 172 14.35
Nov. 9 624,205 102 8.32 2 .16 104 8.63
Nov. 16 624,205 80 6.24 3 .24 83 6.76
Nov. 23 624,205 71 5.72 4 .33 75 6.24
Nov. 30 624,205 43 3.53 1 .08 44 3.64
Dec. 7 624,205 33 2.70 11 .88 44 3.64
Dec. 14 624,205 42 3.48 8 .62 50 4.16
Dec. 21 620,000 44 3.64 10 .83 54 4.52
Dec. 28 614,000 50 4.21 4 .32 54 4.52
Dec. 29-31 614,000 16 3.17 1 .19 17 3.29
Total 503,792 4,158 8.25 749 1.48 4,907 9.73

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TABLE No. 12.--United States naval forces ashore in the United States; Deaths and annual death rates per 1,000 by weeks, 1918, influenza and pneumonia (all forms).

Week. Comple-
ment.
Influenza. Pneumonia
(all forms).
Total
Case. Rate. Case. Rate. Case. Rate.
Jan. 5 106,983 ------ ------ 4 1.92 4 1.92
Jan. 12 112,262 1 0.46 10 4.62 11 5.04
Jan. 19 107,978 ------ ------ 18 8.32 18 8.32
Jan. 26 104,858 ------ ------ 11 5.40 11 5.40
Feb. 2 105,089 1 .49 23 10.92 24 11.85
Feb. 9 103,168 ------ ------ 13 6.24 13 6.24
Feb. 16 100,716 ------ ------ 7 3.58 7 3.58
Feb. 23 102,018 ------ ------ 19 9.36 19 9.36
Mar. 2 105,232 1 .49 15 7.28 16 7.80
Mar. 9 106,648 ------ ------ 20 9.36 20 9.36
Mar. 16 111,257 ------ ------ 31 14.04 31 14.04
Mar. 23 106,557 ------ ------ 23 10.92 23 10.92
Mar. 30 107,821 ------ ------ 17 7.80 17 7.80
Apr. 6 110,782 ------ ------ 16 7.28 16 7.28
Apr. 13 111,942 ------ ------ 12 5.20 12 5.20
Apr. 20 114,400 ------ ------ 8 3.58 8 3.58
Apr. 27 118,090 1 .43 17 7.28 18 7.80
May 4 112,968 ------ ------ 6 2.75 6 2.75
May 11 121,246 2 .83 7 2.96 9 3.84
May 18 122,401 ------ ------ 8 3.38 8 3.38
May 25 126,855 1 .41 2 .78 3 1.19
June 1 132,434 ------ ------ 5 1.92 5 1.92
June 8 139,267 1 .36 1 .36 2 .72
June 15 148,282 1 .35 1 .34 2 .67
June 22 154,248 ------ ------ 4 1.30 4 1.30
June 29 159,415 ------ ------ ------ ------ ------ ------
July 6 166,456 1 .31 1 .31 2 .62
July 13 171,215 ------ ------ 3 .88 3 .88
July 20 175,116 ------ ------ 4 1.14 4 1.14
July 27 186,093 ------ ------ 1 .27 1 .27
Aug. 3 197,643 ------ ------ 1 .26 1 .26
Aug. 10 206,020 ------ ------ 3 .72 3 .72
Aug. 17 207,693 ------ ------ 6 1.45 6 1.45
Aug. 24 314,019 ------ ------ 3 .72 3 .72
Aug. 31 216,654 ------ ------ 2 .47 2 .47
Sept. 7 220,339 8 1.87 3 .67 11 2.54
Sept. 14 234,760 33 6.76 10 2.18 43 9.36
Sept. 21 247,954 225 46.80 11 2.08 236 48.40
Sept. 28 255,066 841 171.08 39 7.80 880 178.88
Oct. 5 254,676 623 126.88 28 5.20 651 132.60
Oct. 12 255,421 496 100.88 19 3.84 515 104.52
Oct. 19 249,392 313 65.00 19 3.95 332 69.16
Oct. 26 250,831 145 29.64 5 .98 150 30.68
Nov. 2 247,020 97 20.28 2 .41 99 20.80
Nov. 9 246,313 70 14.56 1 .20 71 14.76
Nov. 16 244,974 56 11.44 1 .20 57 11.96
Nov. 23 243,385 54 11.44 3 .62 57 11.96
Nov. 30 244,296 33 6.76 ------ ------ 33 6.76
Dec. 7 245,858 27 5.20 9 1.87 36 7.28
Dec. 14 238,666 33 6.76 5 1.04 38 7.80
Dec. 21 239,313 35 7.28 7 1.50 42 8.84
Dec. 28 228,427 41 8.84 2 .45 43 9.36
Dec. 29-31 218,783 12 6.58 ------ ------ 12 6.58
Total 193,818 3,152 16.26 486 2.57 3,638 18.77

--2448--

TABLE No. 13.--United States naval forces afloat and expeditionary forces (including Marines) combined: Deaths and annual death rates per 1,000 by weeks, 1918, influenza and pneumonia (all forms).

Week. Comple-
ment.
Influenza. Pneumonia
(all forms).
Total
Case. Rate. Case. Rate. Case. Rate.
Jan. 5 222,895 ------ ------ 2 0.46 2 0.46
Jan. 12 224,305 ------ ------ 8 1.82 8 1.82
Jan. 19 235,278 ------ ------ 3 .62 3 .62
Jan. 26 245,087 ------ ------ 2 .41 2 .41
Feb. 2 251,545 ------ ------ 2 .41 2 .41
Feb. 9 260,155 ------ ------ 5 .98 5 .98
Feb. 16 269,296 ------ ------ 10 1.92 10 1.92
Feb. 23 274,683 ------ ------ 3 .52 3 .52
Mar. 2 278,158 ------ ------ 7 1.30 7 1.30
Mar. 9 283,431 ------ ------ 17 3.06 17 3.06
Mar. 16 285,511 1 0.18 19 3.43 20 3.64
Mar. 23 296,900 ------ ------ 17 2.96 17 2.96
Mar. 30 302,325 ------ ------ 22 3.74 22 3.74
Apr. 6 306,053 1 .16 7 1.14 8 1.35
Apr. 13 311,582 ------ ------ 7 1.14 7 1.14
Apr. 20 315,813 2 .32 12 1.92 14 2.28
Apr. 27 318,812 ------ ------ 5 .78 5 .78
May 4 330,623 ------ ----- 3 .46 3 .46
May 11 329,034 ------ ------ 4 .62 4 .62
May 18 334,568 ------ ------ 5 .72 5 .72
May 25 336,803 ------ ------ 3 .45 3 .45
June 1 337,913 ------ ------ 2 .30 2 .30
June 8 337,769 ------ ------ 2 .30 2 .30
June 15 335,443 1 .15 ------ ------ 1 .15
June 22 336,166 ------ ------ 2 .30 2 .30
June 29 337,688 1 .15 2 .30 3 .45
July 6 337,336 ------ ------ 1 .15 1 .15
July 13 339,266 ------ ------ ------ ------ ------ ------
July 20 342,054 ------ ------ 4 .57 4 .57
July 27 337,766 2 .30 2 .30 4 .57
Aug. 3 332,905 2 .31 ------ ------ 2 .31
Aug. 10 331,217 ------ ------ 2 .31 2 .31
Aug. 17 336,233 ------ ------ 2 .30 2 .30
Aug. 24 336,596 1 .15 1 .15 2 .30
Aug. 31 340,650 1 .15 1 .15 2 .30
Sept. 7 343,654 1 .15 1 .15 2 .30
Sept. 14 335,922 5 .72 2 .30 7 1.04
Sept. 21 329,417 41 6.24 3 .47 44 6.76
Sept. 28 328,994 148 22.88 25 3.90 173 27.04
Oct. 5 336,073 179 27.56 15 2.28 194 29.64
Oct. 12 342,017 159 23.92 7 1.04 166 24.96
Oct. 19 354,735 165 23.92 2 .29 167 24.44
Oct. 26 359,985 103 14.56 8 1.14 111 15.60
Nov. 2 370,485 73 9.88 ------ ------ 73 7.88
Nov. 9 377,892 32 4.42 1 .13 33 4.52
Nov. 16 379,231 24 3.27 2 .27 26 3.54
Nov. 23 380,820 17 2.28 ------ ------ 17 2.28
Nov. 30 379,909 10 1.35 1 .13 11 1.45
Dec. 7 378,347 6 .78 2 .27 8 1.09
Dec. 14 385,539 9 1.19 3 .40 12 1.61
Dec. 21 380,687 9 1.19 3 .40 12 1.61
Dec. 28 385,573 9 1.19 2 .26 11 1.45
Dec. 29-31 395,217 4 1.22 1 .30 5 1.46
Total 309,974 1,006 3.24 263 .78 1,269 4.09

--2449--

TABLE NO. 14--United States Navy enlisted personnel: Specific admission rates per 1,000 living, for influenza by months according to age groups, Sept. 1 to Dec. 31, 1918.

Age
group.
Comp-
lement
September. October. November. December. Total.
Admis-
sions
Rate. Admis-
sions
Rate. Admis-
sions
Rate. Admis-
sions
Rate. Admis-
sions
Rate.
15-19 138,666 6,649 47.94 3,973 28.65 906 6.46 746 5.37 12,274 88.51
20-24 214,880 22,676 105.52 15,290 71.10 2,873 13.37 2,700 12.56 43,539 202.62
25-29 82,574 7,656 92.59 5,907 71.53 1,161 14.06 1,023 12.38 15,747 190.70
30-34 24,858 1,859 74.78 1,634 65.73 342 13.75 275 11.06 4,110 165.33
35-39 7,700 220 28.57 228 29.61 53 6.88 60 7.79 561 72.85
40-44 3,422 84 24.54 81 23.67 25 7.30 25 7.30 215 62.82
45-49 1,477 29 19.63 45 30.46 11 7.44 20 13.54 105 7.19
50-54 749 15 20.02 13 17.35 3 4.00 7 9.34 38 50.73
55-59 287 3 10.45 6 20.90 2 6.96 6 20.90 17 59.23
60-64 137 3 21.89 3 21.89 ------ ------ ------ ------ 6 43.06
65-69 19 3 157.36 ------ ------ ------ ------ ------ ------ 3 157.89
70-74 21 ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
75-79 10 ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
Total 474,800 39,197 8.41 27,180 57.24 5,376 11.32 4,862 10.24 76,615 161.36

TABLE NO. 15--United States Navy enlisted personnel: Specific admission rates per 1,000 living, for pneumonia (all forms) by months according to age groups, Sept. 1 to Dec. 31, 1918.

Age
group.
Comp-
lement
September. October. November. December. Total.
Admis-
sions
Rate. Admis-
sions
Rate. Admis-
sions
Rate. Admis-
sions
Rate. Admis-
sions
Rate.
15-19 138,666 524 3.77 436 3.14 69 0.49 73 0.52 1,102 7.87
20-24 214,880 1,952 9.08 1,792 8.33 220 1.02 226 1.05 4,190 19.49
25-29 82,574 777 9.40 792 9.59 121 1.46 84 1.01 1,774 21.48
30-34 24,858 165 6.63 222 8.93 31 1.24 27 1.08 445 17.90
35-39 7,700 22 2.84 28 3.63 8 1.03 4 .51 62 8.05
40-44 3,422 11 3.21 3 .87 ------ ------ 2 .58 16 4.67
45-49 1,477 2 1.35 ------ 1 .67 ------ ------ 3 8.80
50-54 749 1 1.33 ------ ------ ------ ------ ------ ------ 1 1.33
55-59 287 ------ ------ 2 6.96 ------ ------ ------ ------ 2 6.96
60-64 137 ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
65-69 19 ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
70-74 21 ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
75-79 10 ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
Total 474,800 3,454 7.27 3,275 6.89 450 .94 416 .87 7,595 15.99

TABLE NO. 16--United States Navy enlisted personnel: Specific death rates per 1,000 living, for influenza, including influenzal pneumonia, by months according to age groups, Sept. 1 to Dec. 31, 1918.

Age
group.
Comp-
lement
September. October. November. December. Total.
Admis-
sions
Rate. Admis-
sions
Rate. Admis-
sions
Rate. Admis-
sions
Rate. Admis-
sions
Rate.
15-19 138,666 175 1.26 212 1.52 24 0.17 17 0.12 428 3.08
20-24 214,880 774 3.60 941 4.37 94 .43 74 .34 1,883 8.76
25-29 82,574 336 4.06 472 5.71 59 .71 35 .42 902 10.92
30-34 24,858 93 3.74 136 5.47 13 .52 13 .52 255 10.25
35-39 7,700 10 1.29 15 1.94 4 .51 4 .51 33 4.28
40-44 3,422 3 .87 ------ ------ ------ ------ ------ ------ 3 .87
45-49 1,477 2 1.35 2 1.35 ------ ------ ------ ------ 4 2.70
50-54 749 ------ ------ ------ ------ 1 1.33 ------ ------ 1 1.33
55-59 287 ------ ------ 1 3.48 ------ ------ ------ ------ 1 3.48
60-64 137 ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
65-69 19 ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
70-74 21 ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
75-79 10 ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
Total 474,800 1,393 2.93 1,779 3.77 195 .41 143 .30 3,510 7.39

--2450--

TABLE NO. 17--United States Navy enlisted personnel: Specific death rates per 1,000 living, for pneumonia (all forms other than influenzal pneumonia) by months according to age groups, Sept. 1 to Dec. 31, 1918.

Age
group.
Comp-
lement
September. October. November. December. Total.
Admis-
sions
Rate. Admis-
sions
Rate. Admis-
sions
Rate. Admis-
sions
Rate. Admis-
sions
Rate.
15-19 138,666 7 0.05 11 0.07 1 0.007 3 0.02 22 0.15
20-24 214,880 47 .21 40 .18 6 .02 17 .02 110 .51
25-29 82,574 28 .33 10 .12 ------ ------ 3 .09 46 .55
30-34 24,858 4 .16 13 .52 1 .04 2 .08 20 .80
35-39 7,700 3 .38 2 .25 1 .04 2 .08 20 .80
40-44 3,422 2 .58 ------ ------ ------ ------ ------ ------ 2 .58
45-49 1,477 1 .67 1 .67 ------ ------ ------ ------ 2 1.35
50-54 749 ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
55-59 287 ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
60-64 137 ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
65-69 19 ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
70-74 21 ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
75-79 10 ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
Total 474,800 92 .19 77 .16 8 .016 30 .063 207 .43

TABLE NO. 18--Case-fatality rates for influenza including influenzal pneumonia and pneumonia (all forms other than influenzal pneumonia) according to age groups, enlisted personnel of the Navy, by months, Sept. 1 to Dec. 31, 1918.

Age
group.
Influenza, deaths per 100 cases. Pneumonia (all forms), deaths per 100 cases.
Sept. Oct. Nov. Dec. Entire
quarter.
Sept. Oct. Nov. Dec. Entire
quarter.
15-19 2.63 5.33 2.64 2.27 3.48 1.33 2.52 1.44 4.10 1.99
20-24 3.41 6.15 3.27 2.74 4.32 2.40 2.57 2.72 7.52 2.62
25-29 4.38 7.99 5.08 3.42 5.72 3.60 1.26 ------ 9.52 2.59
30-34 5.00 8.32 3.80 4.72 6.20 2.42 5.85 3.22 7.40 4.49
35-39 4.54 6.57 7.54 6.66 5.88 13.63 7.14 ------ ------ 8.06
40-44 3.57 ------ ------ ------ 1.39 18.18 ------ ------ ------ 12.50
45-49 6.89 4.44 ------ ------ 3.80 50.00 ------ ------ ------ 66.66
50-54 ------ ------ 33.33 ------ 2.63 ------ ------ ------ ------ ------
55-59 ------ 16.66 ------ ------ 5.88 ------ ------ ------ ------ ------
60-64 ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
65-69 ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
70-74 ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
75-79 ------ ------ ------ ------ ------ ------ ------ ------ ------ ------

Severity of Influenza During the Autumn Epidemics.

While influenza manifested itself in all degrees of severity from the very mild to the overwhelming types of infection wherever epidemics occurred in the Navy during the autumn of 1918, the outstanding feature everywhere, ashore and afloat, was the frequency with which pneumonia of extremely virulent type complicated the disease. Competent pathologists in various parts of the United States have agreed that the pulmonary lesions did not conform to any of the well recognized types of pneumonia.

Different observers in the Navy have reported that it was difficult or impossible at times to say whether pneumonia was present or not during life and it was impossible in many instances to obtain accurate

--2451--

figures relative to the percentages of cases complicated with pneumonia. For this reason, in many instances, only approximately correct case-fatality rates could be determined for pneumonia.

Pneumonia as a complication of influenza at various stations.-- The percentages of influenza cases complicated by pneumonia and case-fatality rates for influenzal pneumonia at various stations are shown in the following table. The figures relate to all cases of influenza occurring at each station, including those transferred to hospital.

Station. Complement. Percentage of
influenza cases
complicated by
pneumonia.
Case-fatality
rate for
influenzal
pneumonia.
Training station, Newport, R.I. 9,493 18.0 26.0
Training camp, Pelham Bay Park, N.Y.:         
     Primary epidemic, September-October 14,220 18.0   26.0  
     Recurrent epidemic, December 14,220 17.5   25.0  
Training station, Hampton Roads, Va. 11,104 12.2   33.5  
Receiving ship, Norfolk, Va. 7,994 15.3   39.18
Training camp, Charleston, S.C. 4,167 5.6   29.0  
Marine barracks, Parris Island, S.C. 10,424 21.0   15.0  
Training camp, Gulfport, Miss. 1,772 11.4   19.04
Training station, Great Lakes, Ill. 44,605 18.19 48.0  
Navy Yard, Mare Island, Cal. 7,657 14.3   24.8  
Fifth naval district ------ 13.16 35.8  
U.S.S. Pittsburgh ------ 11.0   50.9  

Pneumonia as a complication of influenza in hospital cases.--The percentages of pneumonic complications among influenza cases transferred to hospital and case-fatality rates for pneumonia in such cases varied considerably, as shown in the following table:

Hospital. Percentage
of influenza
cases complicated
by pneumonia.
Case-
fatality
rate for
influenzal
pneumonia.
Naval hospital No. 5, Brest, France:    
     Among patients received from organizations in France ------ 38.0
     Among patients received from transports ------ 48.0
Naval hospital, Cape May, N.J. 55.0 24.0
Naval hospital, Key West, Fla. 22.5 16.3
Naval hospital, Norfolk, Va. 30.0 28.6
Naval hospital, Pensacola, Fla. 8.2 27.2
Naval hospital, Philadelphia, Pa. 24.4 47.5
Naval hospital, Portsmouth, N.H. 38.2 32.3
Naval hospital, Washington, D.C. 27.4 19.7

Epidemiological study of influenza for an entire naval district.--Influenza statistics vary considerably for the different individual stations within a naval district. The following analysis of data from the third naval district illustrates this:

--2452--

Principal stations, third naval district. Station
comple-
ment.
Cases,
influenza.
Deaths,
influenza
and
pneumonia.
Case
incidence
(per cent).
Case-
fatality
rate
(per cent).
Epidemic
death
rate per
1,000
influenza
and
pneumonia.
Air station, Bayshore, N.Y. 880 97 6 11.02 6.18 6.81
Air station, Montauk, N.Y. 270 2 1 .74 50.00 3.70
Air station, Rockaway, N.Y. 843 80 6 9.49 7.50 7.11
Ammunition depot, Iona Island, N.Y. 385 53 1 13.25 1.88 2.59
Armed draft detail, New York 2,750 554 21 20.14 3.80 7.63
District section headquarters, Bath Beach, N.Y. 1,260 310 5 24.60 1.61 3.96
District section headquarters, New Haven, Conn. 436 171 3 39.20 1.75 6.88
Federal rendezvous, Brooklyn, N.Y. 1,700 172 7 10.11 4.07 4.11
Receiving ship at New York 5,800 1,049 48 18.08 4.57 8.27
Rifle range, Caldwell, N.J. 752 165 6 21.86 3.64 7.97
Rifle range, Peekskill, N.Y. 750 215 7 28.66 3.25 9.33
Pelham training camp, New York 15,316 2,616 134 17.08 5.12 8.74
Officer material school, Pelham Bay Park, N.Y. 1,111 69 4 6.21 5.80 3.60
U.S.S. Granite State, New York 566 175 2 30.92 1.14 3.53
Totals and averages 32,819 5,728 249 17.45 4.35 7.58
 





New York City:            
     Age 15-25--Males and females 1,240,510 ------ 3,657 ------ ------ 2.94
     Age 25-45--Males and females 1,987,700 ------ 9,999 ------ ------ 5.03

It is to be noted that low case-fatality rates usually coincide with high case-incidence rates and it might be inferred that some stations reported more mild cases of influenza than others. The large and busy stations reported lower case-incidence rates and higher case-fatality rates than the smaller stations. The epidemic death rates for the various stations show greater uniformity.

Outbreaks of influenza presumably occurred simultaneously among civilians and naval personnel in and about greater New Yorik but, whereas the periods of greatest prevalence had passed in some of the naval stations before October 9, the crest of the epidemic in New York City was not reached until October 26. Among those of the naval personnel quartered outside of naval stations or living under conditions which were essentially civilian the incidence followed that of the civil community. This was particularly the case among the personnel of the steam engineering school, Hoboken, N.J., in the navy yard and among the force attached to district headquarters or employed in various offices.

It is not surprising that the epidemic should have run its course in congested stations more rapidly than among civilians. The epidemic reached its peak in the receiving ship September 21 and in City Park Barracks, October 1. These were the two most congested stations. With regard to preventive measures, quarantine was not imposed nor was the general use of masks or prophylactic sprays advised. Stations remote from cities were advised to prohibit city liberty, but stations in New York were advised by the medical aid to the commandant of the district to relieve congested barracks by freely granting liberty. Special preventive measures, which varied greatly in character, were instituted at different stations upon the initiative of the various medical officers.

At the three air stations gauze masks were worn. It will be noted that the epidemic death rates were moderately high at two of them

--2453--

and low at the United States Naval Air Station, Montauk. An epidemic of influenza occurred at that station in March, 1918, when 48 cases developed during a period of 12 days among the crew, then numbering 119. However, considerable change in personnel had taken place in the meantime, only 20 of those were actually attacked in March remaining.

At the receiving ship in New York, in City Park Barracks, at the Federal rendezvous, and at Bath Beach, all of which stations are in New York City, no restrictions were imposed on liberty; masks were not worn and no other personal prophylactic measures were undertaken. At the United States Naval Training Camp, Pelham Bay Park, liberty was restricted and visitors were excluded. This was also the rule on board the Granite State.

Some of the vagaries of epidemics become apparent when the case incidence and case-fatality rates of the training camp in Pelham Bay Park are compared with those of the Federal rendezvous. The former, located at the extreme edge of the city limits, had its men billeted in many rooms of moderate size and imposed a modified quarantine. At the latter, all men were quartered in one very large room and no restriction was imposed on liberty. The building is an armory located in a thickly populated section of Brooklyn. Pelham suffered more than the Federal rendezvous or the station at bath Beach. It is difficult also to explain the differences in rates at Peekskill and Iona Island. These stations are located opposite each other on the Hudson River, 40 miles above New York. The same restrictions were imposed on liberty at both, and presumably each had about the same amount of communication with the city, but they gave respectively the highest and lowest epidemic death rates. One hundred men of the United States Naval Aviation Detail, Keyport, N.J., escaped without a case, although the neighboring city suffered.

Epidemiological studies among personnel of the Navy Department, Washington, D.C.--The figures for the personnel on duty at the Navy Department, Washington, D.C., furnish a means of judging the effects of epidemic influenza among adults living under civilian conditions.

Bureau. Comple-
ment.
Number
of cases.
Number
of deaths.
Case
incidence
(per cent).
Case-
fatality
rate.
Death rate
per 1,000
for epidemic.
Ordnance 303 37 1 12.2 2.70   3.30
Construction and repair 608 90 2 14.3 2.22   3.28
Steam Engineering 583 89 2 15.2 2.24   3.43
Navigation 1,351 431 5 31.9 1.16   3.70
Secretary's office
Chief clerk's office
98 11 0 11.2 ------ ------
Yards and Docks 635 128 2 20.1 1.48   3.14
Compensation Board 41 4 0 9.7 ------ ------
Judge Advocate's office 46 7 0 15.2 ------ ------
Solicitor's office 35 5 0 14.2 ------ ------
General Board 13 3 0 23.0 ------ ------
Supplies and Accounts 1,699 388 8 22.8 2.06   4.70
Medicine and Surgery 150 35 0 23.3 ------ ------
Marine offices (annex and Corcoran Courts) 566 78 0 13.8 ------ ------
Hydrographic offices 163 26 1 15.9 3.84   6.13
Operations (including O.N.I. inspections and survey) 1,170 243 2 20.8 .082 1.70
Total 7,461 1,575 23 21.0 1.46   3.08
Washington, D.C. 1500,000 25,729 21,658 ------ ------ 3.03
1 Estimated.           2 From Sept. 21 to Nov. 15, 1918.

--2454--

As far as the Navy Department was concerned it may be said that the epidemic ended about November 4, although sporadic cases continued to occur. The case-incidence rate, 21 per cent, coincides very closely with that which appears to have prevailed among civilians in various urban communities where morbidity reports were more or less satisfactory and complete.

Overcrowding in offices appears to have been a factor in the spread of the disease among the Navy Department personnel. The case-incidence rate was higher in overcrowded rooms and offices than in those more evenly proportioned. That the rates were not higher under the conditions of overcrowding, which then existed, was in a measure due to the favorable weather prevailing which made it possible to keep all windows open and utilize all means of ventilation. Of course, all preventive measures that were practicable were put into effect, and a sanitation officer made daily visits to all offices for the purpose of survey and to give practical advice. Not only was more complete sanitary supervision exercised but it is fair to say that those who became ill were able to secure medical advice and care more promptly and more regularly than persons under similar circumstances in civil employment in most of the large cities of the country. It should be stated that a great majority of the persons represented by these dat belonged to the age group 20-30, the age group which practically everywhere showed very high incidence rates for influenza and the highest case-fatality rates.

True case-fatality rates for influenza and influenzal pneumonia, entire Navy.--From August 31 to December 31, 1918, there were reported for the entire Navy 91,656 cases of influenza, 6,425 cases of bronchitis, and 8.816 cases of pneumonia (all forms).

The great majority of all cases of pneumonia in the Navy during this period were influenzal in origin and, if it be assumed that all cases were influenzal, these figures would indicate that 9.6 per cent of the cases of influenza were complicated with pneumonia, of no cases diagnosed as acute bronchitis are included, and 8.9 per cent if the 6,425 cases of bronchitis are included. Furthermore, the case-fatality rate for pneumonia as indicated by these figures would be 49.67 per cent. This is obviously much higher than the true rate, but the true rate can not be determined accurately. There is no doubt about the deaths, but it is known that many cases of pneumonia terminating in recovery were not recognized, and in some cases of influenza which resulted in recovery the diagnosis was not changed to pneumonia even though clinical findings suggested or indicated pulmonic complications. In other words, many nonfatal cases of pneumonia were not reported as pneumonia. Every certificate of death received in the bureau was edited by the Division of Preventive Medicine, and in every case of pneumonia where an influenzal origin was indicated or suggested in the history of the case as contained in the body of the report, the death was charged to "influenzal pneumonia."

During the period, August 31, to December 31, 1918, 4,136 deaths from influenza and influenzal pneumonia occurred in the Navy, and the mean strength was 569.470, making the death rate from influenza 7.26 per 1,000, and the case-fatality rate for influenza 4.5 per cent. The latter rate is undoubtedly higher than the true rate because many mild cases of influenza, and sometimes cases of moderate severity, were not admitted to the sick list. It has been estimated at various

--2455--

stations that for every 100 cases of influenza formally admitted to the sick list, from 50 to 75 mild cases were never recorded. With 50 per cent added to the number of recorded cases of influenza the indicated case-fatality rate becomes 3.0 per cent. This figure more closely approximates the true case-fatality rate than 4.5 per cent. In all probability the true case-fatality rate for influenza in the Navy was between 2.5 and 3.5 per cent.

It is more difficult to reach a conclusion with regard to the case-fatality rate for influenzal pneumonia. The figures given above would indicate that pneumonia was a complication in 9.6 per cent of the cases of influenza. This figure is too low but there are no means of accurately determining the true percentage. At various stations where careful study was possible the figures varied from 11.4 to 21 per cent, giving an average of 15.9 per cent and a median figure of 16.25 per cent. Assuming that approximately 15 per cent of recorded cases of influenza in the navy were complicated with pneumonia the indicated case-fatality rate for influenzal pneumonia during the period August 31 to December 31, 1918, would be 30 per cent, or, assuming that all deaths from pneumonia during this period were really due to influenza, 31.8 per cent.

Recognition of Influenza

Influenza is not easily differentiated from other acute respiratory infections when the disease is not epidemic, and for this reason in studying influenza, distinctions must not be drawn too finely between the types of cases occurring during epidemics, and the types reported as influenza before and after epidemics. A sudden onset with malaise and weakness, leading in a few hours to prostration out of proportion to the other clinical manifestations; the prominence of headache, particularly the so-called post-orbital headache; muscular pains, sharp rise in temperature to 101 or 102 degrees of even higher, and leukopenia, appear to be the principal guides to recognition of the true case of influenza, pending agreement as to the value of bacteriological findings or the discovery of a microöganism which can be agreed upon as the causative agent of the disease.

Studies of cases occurring in various outbreaks of influenza in the Navy during this pandemic show a remarkable similarity in the clinical characteristics of the disease all over the world. Inasmuch as epidemics varied considerably in duration and intensity it is not surprising that there was also considerable variation in the proportion of uncomplicated cases, both mild and severe, to the complicated severe cases. Mild, uncomplicated cases occurred everywhere, even when epidemics were at their peaks, and such cases appear to have had the same characteristics wherever they occurred, before, during, and after the primary epidemic. At the majority of naval stations, as well as on board ship, a certain number of cases occurred which were clinically very severe from the moment of onset and terminated fatally, sometimes in less than 36 hours. These cases occurred principally at the height of an epidemic; were uncommon previous to September 1, 1918, and were not often seen after the passing of the primary epidemic.

The outstanding feature of the pandemic was the frequency with which secondary pneumonia of the bronchial type developed. This

--2456--

complication was the cause of death in practically all fatal cases of influenza.

The clinical course in cases complicated by pneumonia varied considerably at each place or hospital. Pneumonia developed early, almost immediately in some cases; in others only after several days of influenza or after a remission, and in some instances after convalescence had apparently begun.

With due allowance for the fact that a hemolytic streptococcus was associated with most or all cases of complicating pneumonia in one place, whereas a pneumococcus predominated in another place, it may be said that there was a remarkable similarity in the cases complicated with pneumonia as well as in ordinary uncomplicated cases of influenza wherever they occurred, not only in all parts of the United States but in England, France, the West Indies, South America, and the Orient. That is, the general picture of influenzal pneumonia was the same all over the world.

In practically all cases of complicating pneumonia a hemolytic streptococcus, a pneumococcus, the Pfeiffer bacillus, or a combination of these microörganisms seemed to play a part in causing the pneumonic lesions. However, it is generally agreed that the pneumonia cases were sufficiently characteristic to stand out as a type different from cases of ordinary pneumonia seen in recent years and more or less different too from the types of broncho-pneumonia which so frequently complicated measles in 1917 and early in 1918.

From various reports, with reference to clinical and post-mortem findings and with regard to statistical data for various stations and ships in many parts of the world, it appears that of 1,000 cases of influenza from 30 to 40 terminated fatally; from 10 to 30 in some places and as many as 90 or more under unusual circumstances. As a rule, from 100 to 200 cases in a thousand had pneumonia complications with definite clinical manifestations. Such cases averaged, perhaps, 150 per 1,000 cases of influenza. A small number of these patients lived only a day or two, and the exact nature of the infection microörganisms and the immunological conditions involved in such cases are still unknown In many of the fatal cases of pneumonia a secondary invader, a pneumonococcus or streptococcus, or both, seemed to play an important if not the paramount rôle in causing death. In some cases the Pfeiffer bacillus was present in the tissues and in cells in great numbers and appeared to be responsible for the pneumonia, inasmuch as it was recovered in pure culture.

The causes of death other than pneumonia were few. Cerebrospinal fever was a not uncommon concomitant infection or sequela at several training stations and in a few ships.

Besides broncho-pneumonia, the following complications were noted:

    Pulmonary edema.
    Pulmonary hemorrhage.
    Empyema.
    Emphysema.
    Edema of the glottis.
    Acute myocarditis.
    Acute endocarditis.
    Acute pericarditis.

--2457--

    Acute nephritis.
    Acute pyelitis.
    Septic embolism.
    Brain abscess.
    Hemiplegia.
    Toxic psychosis.
    Acute neuritis.
    Acute hepatitis.
    Acute cholangitis.
    Acute cholecystitis.
    Liver abscess.
    Acute enteritis.
    Hiccough.
    Splenic abscess.
    Acute periostitis.
    Epistaxis.
    Acute mastoiditis.
    Suppurative cervical adenitis.
    Sinusitis.
    Acute phlebitis.
    Pneumothorax with subcutaneous emphysema.
    Pneumococcus cerebro-spinal meningitis.
    Pfeiffer bacillus cerebro-spinal meningitis.
    Acute encephalitis with multiple abscesses of the brain.

During the calendar year, 1918, the cause of death in 4,155 fatal cases of influenza was assigned as follows:

Influenza (uncomplicated or complication unrecognized) 931
Pneumonia, bronchial 2,432
Pneumonia, lobar 730
Abscess of kidney 1
Acute dilation of the heart 2
Pulmonary edema 1
Embolism 1
Meningitis, cerebro-spinal 25
Acute nephritis 5
Pleurisy, serofibrinous 2
Pleurisy, suppurative 17
Sinusitis 1
Septicemia 5
Hydropneumothorax 1
Erysipelas      1
     Total 4,155

Of the cases of influenza in which complications did not develop--800 to 875 in a thousand, and probably more than 900 is some instances if the truth could be known--the majority were ordinary cases of influenza, similar to the grippe cases of ordinary times. In some of the uncomplicated cases the patient appeared to be very ill for three or four days. On the other hand, there were always numerous mild attacks which either did not prevent the performance of usual tasks or necessitated confinement to bed or quarters for only one, two, or three days. The frequency with which very mild cases were seen leads to the belief that a great many persons were attacked by the disease in such mild form that it was not recognized even as an acute minor respiratory affection.

It is not improbable that approximately 40 per cent of the total naval personnel actually became infected at some time or other in 1918, which would correspond to the figure accepted for the incidence in civilian populations during the 1889-90 pandemic.

--2458--

Influenzal pneumonia.--Some of the cases were very similar in onset to acute lobar pneumonia, and a good many cases were so diagnosed, particularly early in the epidemic. In some instances even the post mortem findings simulated those of acute lobar pneumonia. The more thoroughly cases were studied the less did it appear that the lesions of influenzal pneumonia were ever those of a true lobar pneumonia.

In most cases the onset of pneumonia was not abrupt, and the pulmonary complication developed so unobtrusively that it was likely to be overlooked without careful and repeated physical examinations. Frequently the temperature, respiration rate, and character of the sputum suggested the presence of pneumonia when it could not be found with the stethoscope. A rising white count was also significant. In some instances the pneumonic complication developed within the first 24 hours, but in the great majority of cases not until after 48 hours, and frequently not until after a remission on the third of fourth day. Several observers noted that broncho-pneumonia of some degree could be considered to exist if there was not a cessation of influenza symptoms by the sixth day.

After full development, the distinguishing features of influenzal pneumonia were extreme toxicity, rapid respiration becoming very marked upon the least exertion, early appearance of cyanosis of the lips, ears and finger tips extending to the body before death; a frequent paucity of physical signs in comparison with the obviously critical condition of the patient, pulmonary edema, and abundant watery bloodstained sputum or thin rusty muco-purulent sputum. Of course, in many cases there were physical signs of extensive involvement of the lungs.

The appearance of the patient; his bluish or purplish lips, cyanosis of the ears, ashen cyanosis of the face or blue mixed with red when there was congestion, drooping eyelids, and the "air hunger" which often seemed due more to toxemia and to changes in the blood than to lack of proper aeration in the lungs, made an unforgettable picture in cases where medical treatment was practically without avail.

Many of the cases were regarded as mixed infections and clinically many were septicemias. In the majority of instances blood cultures were negative, but in some streptococci or pneumococci were obtained from the blood during life. Rarely, the Pfeiffer bacillus was found in blood culture.

Not all cases of influenzal pneumonia presented the picture described above. Indeed, reports from various naval hospitals denote considerable variation in clinical manifestations as well as in post-mortem findings at each place during the epidemic, but this was the picture in many of the cases, especially at the height of the epidemic when influenza seemed to be more highly communicable than before or after and when influenzal pneumonia was more prone to occur. It would not do to compare the pneumonia cases occurring at one place early in the epidemic with those occurring later at another place. Pleurisy of some degree complicated the great majority of pneumonia cases at all stages of the epidemic, but there were very few empyemas until after the epidemic had passed, even in patients living as long as 14 days.

--2459--

Physical signs in the chest varied extremely from those strongly suggestive of frank lobar pneumonia to a few subcrepitant r’les only, elicited with difficultly, or no signs whatever. Collections of fluid, emphysematous areas, collapsed areas, extravasations, filled or obstructed small bronchi, confluent areas of consolidation, alterations of the blood and possibly acute toxic neuritis of the vagus and peripheral nerves of the thorax accounted for diverse physical findings. Frequently neither a diagnosis nor prognosis could be based upon physical findings.

Cases of fatal septicemia were reported in which there was no consolidation in the lungs, although there was intense congestion with extensive bronchitis. The bronchioles and alveoli were filled with a fluid resembling hemolyzed blood. Blood cultures in certain groups of such cases gave pure growths of a green-producing streptococcus which sometimes hemolyzed and sometimes did not. This microörganism also grew as a diplococcus at times and was difficult to distinguish from Type IV pneumococci.

Some observers reported cases of hemorrhagic septicemia without lung involvement other than hemorrhages or extravasations in which a pneumococcus was thought to be responsible. It is possible that this microörganism was really a streptococcus of the type just mentioned.

Morbid anatomy.--At the United States Naval Hospital, Chelsea, Mass., post-mortem study of 23 cases at the height of the epidemic which began in Boston August 27, 1918, showed the Pfeiffer bacillus present in the lungs in pure or mixed culture in 19 cases and in the other 4 a hemolytic streptococcus was present in pure culture. The Pfeiffer bacillus was present alone in 6 of the 23 cases. At the United States Naval Hospital, Philadelphia, lung punctures made in 31 cases during life showed the presence of the Pfeiffer bacillus, predominating or mixed with "strepto-pneumococcus," or with M. cararrhalis and other common microörganisms in 15 cases.

The post-mortem findings in the chest with respect to the amount and character of fluid found in the pleural cavities varied considerably. Pleuritis of some degree occurred in the great majority of all cases of influenzal pneumonia. Thoracentesis was frequently and repeatedly performed during life, necessarily affecting somewhat the amount of fluid found after death, which varied from a few cubic centimeters to a liter or more. In most cases the amount was small.

Reference has already been made to the fact that empyema was of very infrequent occurrence during the epidemic. However, it was found in 6 of 56 cases of influenzal pneumonia coming to necropsy at the United States Naval Hospital, Great Lakes, Ill. In most of the cases of fluid found in the pleural cavities was very thin. It was generally noted that the fluid contained little fibrin and was tinged with blood.

The lesions in the lungs were characteristically those of perio-bronchitis and broncho-pneumonia. When the lesions were limited to one lobe, usually a lower lobe was affected. In most cases areas of consolidation were found in both lungs, and the lesions were scattered through several lobes. In many instances confluent areas of consolidation gave the gross appearances of lobar pneumonia.

--2460--

A striking feature which characterized influenzal pneumonia was the great amount of thin, watery, bloody, or blood-colored fluid or very dark fluid containing hemolyzed blood which dripped from the cut surface of the lung, filled the alveoli and bronchioles, and in the form of extravasations under the visceral layer of the pleura in streaks or in areas of from one to several centimeters in diameter resembled bullae of suggested subpleural hemorrhage.

Many composite pictures were presented, but in general it appears that lung findings could be divided into two principal groups, depending chiefly upon whether death occurred in the first few days of the disease or whether life was prolonged for 10 days or more.

Where death occurred early in the disease the picture was that variously described as acute, hemorrhagic pneumonitis, disseminated hemorrhagic pneumonia, primary toxic injury of pulmonary tissue or rapidly fatal septicemia with intense engorgement and localizations in the lungs. The lungs were heavy. The pleural surfaces were smooth and usually wet, bluish gray, purple, or slate colored, and often showed a mottling or dark red streaks due to collections of hemorrhagic fluid or extravasations of fluid containing blood pigment beneath the pleura. The lung surfaces were usually almost completely free from fibrin. Here and there the lungs were partially collapsed. Various portions of the lungs, especially the lower lobes, showed areas of consolidation, and frequently edema and emphysema were noted in areas not consolidated.

The cut surface of the lung varied in color from bluish gray or grayish purple to dark red. As a rule, affected areas were dark red. Sanguineous red or dark fluid dripped from the cut section. "The coarse nodular consolidation of ordinary broncho-pneumonia was not present." Cases of longer duration frequently showed a greater variety of lesions. "The lungs exhibited a constantly varying picture of broncho-pneumonia from a peppering of discreet lobular areas well scattered throughout all lobes to large and often massive confluent areas of consolidation involving 75 per cent of the lungs." "The shades of color of the prominent lobules surrounded by the red of the unconsolidated areas and the pale collapsed areas gave a mosaic appearance." Areas of emphysema were usually present in uninvolved portions of the lungs as well as in tissue intervening between consolidated areas. Sometimes intense engorgement without real consolidation was found, and from areas filled with fluid and presenting a solidified appearance blood stained or dark fluid exuded upon pressure. The lining membrane of bronchioles was intensely congested and even the lining of the trachea and large bronchi was often deep red.

The relatively small amount of fibrin present in the lung of influenzal pneumonia was noted by most observers. Panbronchitis and peribronchitis were commonly found. The peribronchial and bronchial lymph glands were generally enlarged, intensely inflamed, and often edematous.

In cases of longer duration, coming to necropsy after 10 or more days of illness, more extensive and more complete consolidation was usually found and dilation of bronchioles, congested in the cases of short duration, showed extensive necrosis in the late cases and the bronchi frequently contained thin purulent material or pus.

--2461--

In some of the more prolonged cases diffuse and confluent small abscesses were noted with yellow pus exuding from the cut surface. Fibrino-purulent material was present in many of the late cases. In some instances bronchiectasis was extensive. In general, a prominent feature in the cases of 10 or more days' duration was extensive bronchitis and peribronchitis with foci of broncho-pneumonia in various states from grayish consolidation to abscesses containing creamy pus. In these cases the lungs were dryer but there were traces of previous engorgement. In many instances there were evidences of organization taking place in the alveoli and dilated bronchioles.

In cases coming to necropsy after 14 days of pneumonia inter-lobular fibrino-purulent pleural exudates were not uncommon.

"In sections studied microscopically from the early stage of pneumonia it is more evident than in gross that a general bronchitis and especially bronchiolitis precedes the infiltration of alveoli. One finds in unconsolidated areas, bronchioles filled with an exudate composed of polymorphonuclear and mononuclear leucocytes with varying amounts of fibrin and amorphous hyalin material. The infundibula and air vesicles subtended by the bronchiole may contain an exudate of leucocytes with little or no fibrin, forming a small focus of broncho-pneumonia. More characteristic of this stage of inflammation is a lesion of the walls of certain infundibula and air vesicles in the neighborhood of, and within the latest areas of consolidation. A hyalin membrane partially or completely covers the walls of these air spaces. The membrane is irregular in thickness, sometimes stratified with occasional cells within narrow clefts. It tends to be thickest over the angles of the wall, though it may be so abundant as to fill an alveolus.

"In older foci of pneumonia leucocytes are the predominant inflammatory element, with small amounts of blood and fibrin, but in the diffusely consolidated patches or lobes of short duration, serum, fibrin, and red cells are most conspicuous. Especially prominent are the large areas of hemorrhage from capillary rupture. In certain areas numerous focal necroses of alveolar walls are observed. In older lesions the smaller bronchi contained plugs of leucocytes, fibrin, and hyalin material, and their epithelial lining was partially or completely ulcerated and covered by a fibrino-purulent membrane."

Most of the victims in influenza in the Navy were robust young men when attacked and the numbers of these well-developed and well-nourished bodies at necropsy made a spectacle sad beyond description.

Extreme engorgement of the whole venous system with distension of subcutaneous and abdominal veins filled with a thin black fluid, watery in consistency, was sometimes noted. The right side of the heart was then acutely dilated. Frequently there was no marked alteration in the size of the heart. "The heart muscle commonly had a glazed or scalded appearance." It was noted at times that the pectoral and recti muscles presented the same appearance. Acute degenerative myocarditis was commonly found. Reports made little reference to the condition of the cardiac valves. Acute vegetative endocarditis of the mitral valve was noted in one instance at the United States Naval Hospital, Great Lakes, Ill.

The spleen, liver, and kidneys, as a rule, exhibited varying degrees of congestion. Active acute nephritis was infrequently found. A

--2462--

report from the United States Naval Hospital, Great Lakes, Ill., stated that little or nothing worthy of special note was found in organs other than the lungs in the acute pneumonia cases. Complications were found in cases where death occurred later on, after the primary acute attack had subsided. The spleen was seldom enlarged to any marked degree. It was usually firm. The list of complications given above indicates the character of lesions found in these organs in unusual instances.

In a report from the United States Naval Hospital, Philadelphia, Pa., intense congestion of the adrenal bodies without progressive inflammatory changes was noted. A report from the United States Naval Hospital, Chelsea, Mass., noted small foci of hyalin necrosis in the adrenal bodies in a majority of the cases in which death occurred four or five days after the onset of pneumonia.

First and last, leptomeningitis was found in a good many instances. Sometimes a pneumococcus was recovered from the meninges; sometimes a streptococcus; and rarely, the Pfeiffer bacillus. As previously noted, brain abscesses were occasionally found. Edema of the brain was frequently noted.

Other findings noted in rare instances at post-mortem examination were hyalin degeneration, necrosis, rupture, and hemorrhage into one or both of the abdominal recti muscles, acute arteritis, phlebitis, and septic emboli with resulting infarction of the brain or of one or another of the parenchymatous organs.

Clinical Manifestations of Influenza and Influenzal Pneumonia
as 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.

--2463--

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

--2464--

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

--2465--

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

--2466--

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

--2467--

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

--2468--

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:

White blood count  
6,950
Polymorphonuclear leucocytes
per cent
67.5
Small lymphocytes
do     
21.2
Large lymphocytes
do     
3.8
Mononuclear leucocytes
do     
4.4
Transitional cells
do     
2.1
Eosinophiles
do     
.7
Basophiles
do     
.3

--2469--

The following is a composite blood picture in 100 cases of influenzal pneumonia:

White blood count   17,680
Polymorphonuclear leucocytes per cent 82.8
Small lymphocytes do      8.3
Large lymphocytes do      2.1
Mononuclear leucocytes do      2.6
Transitional cells do      3.8
Eosinophiles do      .3
Basophiles do      .1

A report of influenza cases treated in the United States Naval Hospital, Chelsea, Mass., during the height of the primary epidemic states that the average white count was 4,900, but that over half the patients had white counts of less than 3,000 and that the cases in which broncho-pneumonia developed all showed a low blood count.

At the United States Naval Hospital, Puget Sound, Wash., the following findings were obtained in 10 fatal cases of the acute hemorrhagic pneumonitis type attributed to severe streptococcus septicemia complicating influenza.

Case No. Admitted. Died. Average
temperature.
Average
white
count.
1. 24 24 104.0-105.0 (1)
2. 24 26 105.0 4,000
3. 25 27 103.0-105   3,400
4. 25 27 104.0-105   1,500
5. 26 27 104.6-105   3,000-4,000
6. 24 28 104.6-105.6 5,400
7. 24 28 103.0-104   6,800
8. 25 29 105104  104   4,000
9. 29 30 104104  104   4,600
10. 25 30 103.8 3,800
(1) Not taken. Dead two hours after admission.

At the United States Naval Hospital, Great Lakes, Ill., in 571 cases of influenza and influenzal pneumonia blood findings were:

White-blood counts of-- Per cent.
  5,000 or less were found in 15.5
  between 5,000 and 10,000 in 38.3
  between 10,000 and 15,000 in 22.9
  15,000 or over in 24.1

It was noted that counts taken during the height of the acute attack shortly after admission to hospital showed a normal count or a definite leucopenia in practically every case.

A report from the United States Naval Hospital, Philadelphia, Pa., stated that a high or rising white count was maintained in cases of influenzal pneumonia which were progressing favorably, although a falling count, while in general indicating an unfavorable clinical state, seemed not necessarily to define a fatal issue. Many cases with white counts slowly decreasing for several days eventually recovered. An interesting and valuable observation in daily blood examinations was the gradual or sudden change from the blood picture of uncomplicated influenza to that of influenzal pneumonia. By noting the rising white count and reduction in the percentage of small lymphocytes it was frequently possible to anticipate clinical findings of broncho-pneumonia by several days. In a few instances neutrophilic

--2470--

degeneration of polynuclear leucocytes was observed and marked granulation of lymphocytes was noted in one case in a series of over 200 blood examinations.

The following tables show in detail the leucocyte and differential count findings in different series of uncomplicated influenza cases and in different series of influenzal pneumonia cases:

Table No. 19.--Leucocyte counts in 28 early cases of influenza from one war, United States Naval Hospital, Chelsea, Mass., Sept. 1918.

Cases. W.b.c. Poly. Lymph. L. Mono. Trans. Eosin. Baso.
1 6,200 76 20 2 2 ------ ------
2 6,800 25 38 1 5 ------ 1
3 8,400 77 14 3 6 ------ ------
4 10.000 73 25 1 1 ------ ------
5 5,600 44 50 ------ 6 ------ ------
6 6,800 72 24 2 2 ------ ------
7 7,200 80 20 ------ ------ ------ ------
8 7,200 88 12 ------ ------ ------ ------
9 4,400 54 44 2 ------ ------ ------
10 8,000 74 20 4 2 ------ ------
11 6,800 68 30 2 ------ ------ ------
12 6,600 52 45 ------ 2 1 ------
13 4,200 60 40 ------ ------ ------ ------
14 4,600 50 46 2 2 ------ ------
15 5,200 52 46 2 ------ ------ ------
16 5,800 48 52 ------ ------ ------ ------
17 4,200 48 52 ------ ------ ------ ------
18 6,800 64 28 4 2 2 ------
19 7,200 72 26 ------ ------ 2 ------
20 6,800 68 30 ------ 2 ------ ------
21 4,600 66 34 ------ ------ ------ ------
22 5,800 40 56 ------ 4 ------ ------
23 8,600 75 24 ------ ------ 1 ------
24 7,200 78 16 4 2 ------ ------
25 4,400 56 36 4 4 ------ ------
26 4,200 68 32 ------ ------ ------ ------
27 5,000 70 28 2 ------ ------ ------
28 5,400 56 43 ------ 1 ------ ------
Average 6,700 63.7 33.3 1.2 1.2 .21 .035

Table No. 20.--Leucocyte counts in 25 cases of typical influenza, United States Naval Hospital, Philadelphia, Pa., Sept. 26 to Oct. 26, 1918.

W.b.c. Poly-
nuclear.
Small
lymph.
Large
lymph.
Mono-
nuclear.
Trans-
itional.
Eosino-
phile.
Baso-
phile.
5,600 58 36 2 3 1 ------ ------
4,800 65 30 4 1 ------ ------ ------
6,300 68 20 7 3 1 1 ------
8,400 80 15 2 2 1 ------ ------
5,100 77 12 ------ 6 5 ------ ------
8,000 65 15 5 10 5 ------ ------
8,000 77 10 ------ 11 2 ------ ------
6,800 55 28 4 10 2 ------ ------
7,900 58 27 ------ 12 ------ 3 ------
3,500 80 8 6 4 2 ------ ------
6,300 80 20 ------ ------ ------ ------ ------
4,900 71 26 1 ------ 2 ------ ------
7,000 79 12 6 3 ------ ------ ------
8,000 76 15 4 2 3 ------ ------
6,700 61 21 10 7 1 ------ ------
5,800 80 10 5 2 3 ------ ------
3,600 67 23 ------ 7 3 ------ ------
6,500 63 29 ------ 5 3 ------ ------
5,800 77 18 1 3 ------ 1 ------
7,200 71 20 6 ------ 2 ------ 1
6,900 71 19 4 ------ 3 2 1
7,100 73 22 3 1 1 1 ------
5,900 69 22 4 ------ 3 2 ------
6,900 71 19 4 ------ 3 2 1
5,400 65 25 2 6 2 ------ ------

6,336 69.5 19 3 4 2 1.5 1

--2471--

Table No. 21.--Leucocyte counts in 31 cases of influenzal pneumonia from one ward, United States Naval Hospital, Chelsea, Mass., Sept., 1918.

Case. W.b.c. Poly. Lymph. Trans. L. Mono. Baso. Eosin. Temp-
erature
° F.
1 26,200 81 18 1 ------ ------ ------ 104    
2 29,000 89 10 1 ------ ------ ------ 100    
3 14,600 73 26 1 ------ ------ ------ 104    
4 14,600 80 19 ------ ------ 1 ------ 100    
5 13,600 71 24 3 ------ 2 ------ 104    
6 10,000 82 17 1 ------ ------ ------ 99    
7 37,000 75 20 1 2 2 ------ 103    
8 17,600 75 16 4 5 ------ ------ 102    
9 29,900 91 8 1 ------ ------ ------ 100    
10 17,200 78 19 2 1 ------ ------ 103    
11 10,000 78 20 2 ------ ------ ------ 99    
12 7,000 88 10 2 ------ ------ ------ 99    
13 13,000 80 20 ------ ------ ------ ------ 102    
14 17,000 87 10 3 ------ ------ ------ 104    
15 13,600 86 12 ------ 2 ------ ------ 102    
16 28,800 82 14 2 2 ------ ------ 102    
17 4,600 78 19 2 1 ------ ------ 103    
18 14,800 96 4 ------ ------ ------ ------ 104    
19 12,600 70 28 2 ------ ------ ------ 105    
20 12,200 84 16 ------ ------ ------ ------ 103    
21 7,800 67 29 3 1 ------ ------ 101    
22 6,400 66 34 ------ ------ ------ ------ 104    
23 7,400 53 46 1 ------ ------ ------ 101    
24 10,000 56 42 2 ------ ------ ------ 99    
25 3,600 84 16 ------ ------ ------ ------ 104    
26 16,800 60 36 3 ------ ------ 1 99    
27 6,800 56 40 4 ------ ------ ------ 104    
28 9,000 61 36 3 ------ ------ ------ 99.5
29 12,200 82 16 2 ------ ------ ------ 103    
30 15,800 76 22 2 ------ ------ ------ 100    
31 19,400 78 18 2 2 ------ ------ 102    
Average 13,980 76.23 21.45 1.61 .52 .16 .03 101.8

Table No. 22.--Leucocyte counts in 25 cases of influenzal pneumonia, United States Naval Hospital, Philadelphia, Pa., Sept. 26 to Oct. 26, 1918.

W.b.c. Poly-
nuclear.
Small
lymph.
Large
lymph.
Mono-
nuclear.
Trans-
itional.
Eosino-
phile.
Baso-
phile.
22,600 95 2 1 ------ 2 ------ ------
13,600 88 6 1 2 3 ------ ------
12,100 75 3 3 9 6 2 2
16,000 77 13 4 1 3 2 ------
16,500 85 10 ------ 1 4 ------ ------
12,000 89 3 ------ 4 4 ------ ------
15,600 90 1 1 2 6 ------ ------
49,900 86 ------ 1 1 12 ------ ------
69,600 92 2 ------ 1 5 ------ ------
24,300 87 2 2 4 5 ------ ------
22,800 88 12 ------ ------ ------ ------ ------
14,000 86 7 ------ 2 5 ------ ------
20,200 84 3 4 4 5 ------ ------
19,000 91 2 1 1 5 ------ ------
43,000 98 1 ------ 1 ------ ------ ------
25,600 82 10 1 2 5 ------ ------
25,000 82 2 2 9 5 ------ ------
20,900 86 5 ------ 4 5 ------ ------
17,500 77 20 1 1 1 ------ ------
18,900 81 14 ------ 4 1 ------ ------
19,600 78 12 5 1 3 1 ------
15,600 78 10 5 4 2 1 ------
23,800 82 16 ------ ------ 2 ------ ------
13,600 82 17 ------ ------ 1 ------ ------

23,212 85.24 7.04 1.28 2.32 3.8 .24 .08

Urine.--Reports indicate that serious renal complications were very rare. At the United States Naval Hospital, Great Lakes, Ill., albumin was reported present in about 20 per cent of the urines examined.

--2472--

Casts were found only occasionally. Acute nephritis with bloody urine and edema occurred in 7 of 2,924 cases of influenza.

On board the U.S.S. Solace albumin and granular casts were found in the urine in about 10 per cent of the cases treated.

At the United States Naval Hospital, Philadelphia, Pa., in nearly all cases seriously ill the urine contained albumin and occasionally casts, but there was never acute involvement of the kidneys or evidence of serious renal changes. Functional kidney tests made with phenol-sulpho-phthalein were unsatisfactory and did not give any information of importance. There were a number of cases of retention of urine necessitating catheterization a few times. Of 2,130 urines examined, 614, or 28.8 per cent, contained albumin; 204, or 9.6 per cent, pus cells. Casts were present in 192 or 8.6 per cent. Passive congestion of the kidneys was common. The urine was diminished in quantity and usually showed only a trace of albumin, high specific gravity, a few hyalin and granular tube casts, and not infrequently a number of red blood cells. These findings were sometimes interpreted as indicating acute toxic nephritis, but clinically it was impossible to recognize evidence of uremia, the symptoms of which, if present, were merged in the picture of toxemia.

Skin.--Judging from Navy reports, lesions of the skin were neither common nor characteristic. Herpes of the face, erythema, purpuric spots, purpura hemorrhagica and eruptions more or less like those of scarlet fever and measles were mentioned in a few reports.

A report from the United States Naval Hospital, Philadelphia, Pa., states that a papular eruption was observed on the back and, to a lesser extent, on the front of the body in many cases upon admission ito hospital or later during the course of the disease. The papules were frequently capped with minute pustules varying in size from pin point to pinhead.

Urticaria occurred not infrequently in cases where serum was used.


Source: Annual Report of the Secretary of the Navy, 1919 -- Miscellaneous Reports. (Washington: Government Printing Office, 1919). pp 2414-2506.


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