Intense hyperemia and edema were the principal symptoms. No doubt these conditions occasionally developed secondarily to the terrible paroxysms of coughing. Acute inflammatory edema of the glottis, necessitating tracheotomy, we noted in a girl aged nineteen upon the third day of her attack of influenza. "In this case there was neither coryza nor the signs of tracheitis or bronchitis. The larynx alone was the seat of a severe inflammation. The abscess of the larynx opened spontaneously some days after the tracheotomy had been performed, with a copious evacuation of pus."* Cases of acute edema of the glottis were described by Petrina, Landgraf, and Norris-Wolfenden; Duflocq considers it to be a frequent occurrence. Cases of inflammation of the larynx with resulting abscess formation, viz., of phlegmonous laryngitis, were described by H. Rieger, Rethi, M. Schaffer, and by the latter as a sequela of influenza. A case of laryngitis ulcerosa hypoglottica, with gangrenous ulcers, is mentioned in the German army report, and Rethi describes a case of perichondritis thyreoidea.
Hemorrhagic laryngitis, the laryngoscopic picture of which we cannot describe here, was observed by us in three cases. The relative frequency of this hemorrhagic variety is noted in the descriptions of Lowenstein, B. Frankel, Heymann, Marano, and others.
It is important to remember that an admixture of blood with influenza sputum may be due to hyperemia of the laryngeal mucous membrane. Thus Ley den reports cases of hemorrhage from the larynx. Subglottal edema, laryngitis hypoglottica, isolated edema of the inter arytenoid folds, slight ulcerations of the vocal cords (Le Noir, Betz, Klebs, Kuskow), and laryngitis crouposa have also been observed.
Paralysis of the muscles of the larynx or of the recurrent laryngeal nerve after influenza have now and then been seen, either isolated or in combination with other paralyses. Two cases of paralysis of the posticus are noted by Rethi.
Hyperemic and inflammatory processes in the bronchial mucous membrane are among the most frequent and important local affections of influenza. To our previous statement above, that any part of the respiratory apparatus may be affected primarily and alone, we may add that subsequent extension of the inflammatory process to other parts of the respiratory apparatus is the rule.
* Our influenza lectures, p. 27.
The implication of the trachea can be directly observed on laryngoscopic examination by the intense scarlet appearance of its mucous membrane. It is further characterized by the tickling and burning pains along the course of the trachea and under the sternum. Pressure upon the sternum is painful and often produces cough.
The convulsive paroxysmal cough which so often occurs as a symptom of the influenza bronchitis depends, in our opinion, upon the inflammation of the trachea, especially at the point of bifurcation, and of the main bronchi. Many deem this cough to be a nervous phenomenon and say that it is due to a direct irritation of the cerebrospinal cough center by the toxins of influenza. As against our view, they affirm that this spasmodic cough frequently has no relation to the perceptible auscultatory bronchial phenomena and that it is often absent in widely disseminated, intense bronchitis. It is obvious that these objections to our opinion of the tracheobronchial origin of the spasmodic cough are irrelevant.
The spasmodic cough often occurs in paroxysms, especially at night, or at definite times during the day; sometimes it torments the patient continuously. Severe attacks of suffocation even may result.
The observers of some of the oldest epidemics already emphasized the severe, spasm like character of the cough of influenza. Th. Short, in 1510, mentions it as a " terrible tearing cough, . . . so violent a cough that many were in danger of suffocation." The fact that the name "Coqueluche" was applied first (1510) to influenza and later transferred to whooping cough, probably depends on the characteristic spasmodic cough which occurs in both affections. On account of the loud cough the influenza of 1580 was called "sheep's cough." Pasquier attributes to the violent cough in the epidemic of 1410 the frequent hemorrhages and the abortions in pregnant women.
Catarrh of the air passages was noted in Hamburg (Schulz) in 53 per cent.; in Leipsic (Krehl), in 82 per cent.; in Wurzburg (Anton), in 59 per cent.; in Munich (Stintzing), in 57 per cent.; and by Robertson in 77 per cent, of cases.
The bronchitis of influenza is sometimes diffuse, distributed over most of the bronchial ramifications, sometimes limited to one lobe of the lung, and quite sharply defined. The latter is an important peculiarity of the bronchitis of influenza, and points to the localized development of the specific bacilli in definite parts of the bronchial tract.
When bronchitis affects one or both upper lobes only, a doubt often arises whether we have not to deal with an apical pulmonary phthisis.
The dry or moist character of the bronchitis is further characterized by either the absence of any sputum or by copious expectoration which may increase to a veritable bronchorrhea. The auscultatory phenomena are very manifold, depending, as they do, on the extension of the bronchitis into the larger and medium sized bronchi or even into bronchioles. The thorax of influenza patients often presents a truly diagrammatic picture of the most diverse kinds of rhonchi.
Of special interest are those cases to which Graves and Biermer have called attention, in which a marked dyspnea exists unaccompanied by any abnormal physical signs. The respiratory murmur is everywhere vesicular. There may be a rale here and there, but nothing to point to a central pneumonia; sputum is entirely absent. Graves thought these cases were the result of a direct irritation of the vagus, and emphasized the remittent or intermittent character of the dyspnea. We agree with Biermer's interpretation; he says: "It seems to us more likely that a congestion of the lung, which occurs so frequently in influenza, and so long as there is no edema gives but few signs on percussion or auscultation, is the cause of this exaggerated dyspnea."