War Surgery and Medicine
Clinical Review of 1942 Epidemic
Clinical Review of 1942 Epidemic
At the onset of epidemics the cases were milder than those seen in previous years and had fewer complications, but as time went on they became more severe, the icterus lasted longer, debility was greater, and relapses more frequent. As the greatest number were mild they form the basis of this description, but there were, during the later stages, all types, as will be seen in the text. Although it is recognised that icterus is only one symptom of this disease, it is convenient to divide it into two stages, the pre-icteric and the icteric.
Pre-icteric Stage: In all epidemics in the 2 NZEF this was the period of greatest malaise and discomfort, and was the one most often spent outside hospital. Many examples, however, were able to be studied in the wards, and the briefest statement to cover this stage would be that it was usually pyrexial illness associated with acute gastritis. That acute gastritis is present was proved at post-mortem in one case, and in another, when an ulcer in a Meckels diverticulum perforating the mucous membrane showed the typical changes on the third day of the pre-icteric stage.
The onset was usually sudden with a close resemblance to sandfly fever, presenting a mild shivering attack, temperature 102–103, headache, generalised aches and pains, backache, and considerable mental depression. Some cases were apyrexial or had a mild fever only. Two presented as initial symptoms a generalised urticaria which cleared and recurred during the first three days of the illness. The icteric tinge of the skin was readily seen in urticarial wheels. Whatever opened the train of symptoms, be it fever or just malaise, within twenty-four hours the classical features of this stage appeared, dyspepsia and anorexia, which were almost universally present and were the most striking and most complained of symptoms and the greatest cause of discomfort to the patient. No matter if fever were present or not, loss of appetite, nausea, lassitude, general malaise, and indigestion were always regarded with suspicion, and jaundice expected and waited for.
Anorexia was frequently complete and associated with nausea, occasional vomiting, and, in a few instances, persistent hiccough. Dyspepsia was persistent, severe, aggravated by food, and failed to respond to alkalies. Constipation was common and diarrhoea rare, the tongue was clean and moist. Fat intolerance was seen early, and any appetite that was present was capricious. This pre-icteric stage lasted five to seven days, but varied from none to twenty-one days. The dyspeptic symptoms usually became steadily more severe and the pyrexia followed no uniform pattern, but varied between a chart persistent at 101 or 102, one with a daily swing between normal page 508 and 102 and 103, a completely irregular picture, a low fever of 99 or 100, or one that settled to normal within two or three days and stayed there.
From the first or second day there was pain under the right costal margin, both at rest and on movement, tenderness on pressure in this region, and a liver edge palpable one inch below the rib edge. Although the liver was enlarged in practically all cases, it was the exception to feel a spleen, the fauces were normal, the breath not offensive and the facies unchanged, but the patients felt ill and miserable, were unable to concentrate, and difficult to satisfy.
General physical weakness was felt by many of those whose pyrexia and dyspepsia were not of sufficient severity to require evacuation to hospital, and that, combined with a loss of interest and inability to concentrate, eventually decided many to report sick.
Rashes: Two cases were seen who presented a rash typical of typhus fever during this stage, but because of the mildness of the illness and the presence of all other typical signs of hepatitis were accepted as such.
This pre-icteric stage, which proved a source of humiliation to many medical officers in the early days of the epidemic and soon became easily recognised, passed insensibly into the icteric stage.
Icteric Stage: The full development of jaundice normally occupied five to seven days, but was noticed to be as short as three days or, in the severe cases, to deepen steadily for as long as three weeks. At first the urine was noticed to be getting dark, and it was surprising how many of the milder cases continued at work until this stage. Two days later a tinge of yellow was visible in the conjunctival folds of the lower lid, which spread concentrically towards the pupil, and on the fifth day the conjunctiva was evenly and deeply stained, the urine mahogany in colour, and the skin evenly and faintly yellow. In the majority of cases this stage of icterus was obvious but not severe, and reached its full intensity in five to seven days or less. The length of the disease could normally be estimated from the depth of jaundice after one week. Some mild cases were already beginning to clear or had reached a stationary stage by the fifth day, whereas the more severe and prolonged cases were still deepening in colour. It followed in most cases that the degree of icterus reached by then indicated the rapidity with which it would clear and the extent of the resulting debility. A few exceptions to this occurred, in which cases a sudden increase in the severity indicated a more prolonged and severe illness.
The temperature if not already normal at the onset of the icterus became so very soon, settling by lysis, and only rarely did pyrexia remain without heralding the presence of some complication or intercurrent infection. The dyspepsia and anorexia commenced to page 509 improve once jaundice appeared, and in 90 per cent of cases was completely gone when the jaundice was fully developed. As the dyspepsia vanished the appetite became enormous, and in some cases most capricious, being only satisfied by large quantities of tomatoes, cucumbers, or oysters. A certain fat intolerance remained in some and lasted for several weeks.
In the mildest type of case (in this series over 50 per cent) jaundice began to fade very soon after it was fully developed, that is, from the fifth to the seventh day. The fading was normally rapid and was almost gone about the fourteenth day after its appearance, leaving only a mild staining of the conjunctiva. The fading took place, first from the skin, then from the conjunctiva and lastly from the urine, which usually showed a trace of bile on testing for several days after all else appeared normal.
In a considerable number, however, the jaundice remained stationary with daily fluctuations for about seven days and cleared in a further seven to ten days, whereas the most severe continued with deep icterus up to a period of six weeks or more before clearing. The longest case of icterus in this series was eight weeks.
During the stage of clearing all symptoms had usually gone except those of weakness and lassitude. The stools darkened early and the urine became paler early but was the last to clear completely, as determined by laboratory tests.
During the stage of fully developed icterus the liver could be felt one to one and a half inches below the costal margin. In cases of prolonged or deepening icterus it would enlarge still further up to 2.inches or even more, but once the jaundice began to fade in nearly all cases it returned to normal size with rapidity.
In the majority of cases in fourteen to twenty-one days after the onset of jaundice the patient would be quite clear again with a liver of normal size and would commence to get up. This was taken slowly and a week allowed to reach the stage of being up all day before going to a convalescent depot for a further two or three weeks.
In the more severe cases, which were rarely seen early in the epidemic, but formed a large proportion of those at the end, the pre-icteric stage presented no unusual features, but the onset of the icterus was not always accompanied by fall in temperature and return of appetite.
The jaundice gradually increased, or did so in a series of exacerbations, while the irregular fever persisted for seven to ten days and the dyspepsia diminished only gradually, and did not vanish. Malaise and lassitude became more evident and sleeplessness the rule, the skin became deeply yellow, and in those whose jaundice page 510 lasted four to eight weeks pruritis was severe, haemorrhages frequent, and loss of weight alarming.
No particular type of patient or one belonging to any particular age group was more affected in this way than any other, and in this series no deaths occurred in the later stages no matter what the extent or severity of the jaundice.
Persistent Pyrexia: Where this occurred and lasted one or two weeks during the icteric stage, in the absence of any recognisable complications it indicated a severe and prolonged illness. It was an infrequent complication.
Distended Abdomen: This was seen in several cases, and if associated with fever suggested an accompanying typhoid infection. Although a few cases did have this as a superadded infection, the majority of cases did not, and the disorder vanished without therapy.
Pruritis: This was a distressing accompaniment of some of those cases in which icterus was prolonged and deep. It became worse towards evening and at night, was generalised and difficult to relieve. One case only responded brilliantly to ephedrine gr.½, whereas others received temporary relief from luminal, and calamine and phenol lotion.
Haemorrhage: Cases severe enough to show pruritis often showed signs of a haemorrhagic tendency in areas subjected to scratching and other mild traumata. This was usually an indication of more severe haemorrhages to come from lips, gums, nose, stomach, bladder, and rectum, but prompt exhibition of vitamin K intramuscularly prevented any of these becoming of serious importance.
Recurrent Icterus: A recurrence of a fading icterus was not infrequent. In some cases it developed when the original icterus had almost faded. It only increased the time of the illness and the convalescence necessary. In many cases it seemed to be related to indiscretions such as getting out of bed without permission or unwarranted exercise in the earliest stages of getting up.
Relapses: These were of two types:
With Icterus: Presenting a complete picture of the whole disease, usually much more severe and prolonged than the original illness. These relapses occurred three to four weeks after the complete subsidence of the original infection, and in a few cases second relapses also occurred.
Without Icterus: These cases presented a picture of acute gastritis and were recognised by the patient as being identical with his original symptoms, were associated with a slight enlargement of the liver, and took three to four weeks to recover.page 511
There is no evidence that these relapses were related to the taking of alcohol.
It is estimated that the relapse rate was 3 to 4 per cent.
Persistent Liver Enlargement: Mild cases of hepatitis usually had normal livers on discharge from hospital, but in the more severe and relapsed cases enlargement tended to persist and was associated with recurrent dyspepsia and malaise. Enlarged livers have been found three or four months after the recovery from icterus. These patients were far from well and required regrading. The future of these men is uncertain at present, but some, seen six years later, have normally sized livers and no symptoms.
Mental Symptoms: Examples of mild depression were often seen, but in prolonged icterus confusional states, which recovered completely during convalescence, were common.