The epidemic of influenza which swept over the world and reached the
United States in August 1918, starting in at the Atlantic sea-board
cities, developed rapidly there and passed westward over the country.
It reappeared the following winter.
=Epidemiology.=—In the United States it was called Spanish influenza,
as it was at its worst in Spain at the time it broke out here and was
thought to have been brought from that country.
In Europe it was called the Ukrainian influenza and in southern Russia
it was said to have emanated from the Orient. No country in the world
was exempt. It was at one time thought to be a type of the pneumonic
plague and while plague is the severest toxemia known many cases of
Spanish influenza were equally as prostrating and fatal as the ordinary
type of pneumonic plague. The bacillus pestis was never proved to be
the cause of this pandemic of influenza but the clinical analogy was
very evident.
A study of European conditions of health and hygiene shows how
reasonable it is to believe that some disease would develop and sweep
a world lowered in vitality and immunity by the abnormal conditions
of war. Every known communicable disease was raging in Europe and
Asia where millions of people existed under exceedingly poor hygienic
conditions.
The period of incubation of influenza was extremely short, averaging
about two days. All ages were attacked, although persons over 60
rarely. Those between 25 and 35 seemed to be the most susceptible but
it was, perhaps, because they were in active life and more exposed.
There is considerable evidence that the disease was not air-borne but
conveyed by contact with active cases. The secretions of the mouth,
nose and eyes were considered the active carriers. Masks, made of
several layers of gauze fastened over the face, have been worn by many
people but experience taught that their use did not avail against
infection.
=Mortality.=—The mortality under drug medication as shown in a
statement by Henry S. Bunting was as follows: “New York City 9.8%;
Chicago 14.5%; Boston 27%. Osteopathy’s influenza salvage represents
the difference between these figures and the low score of one fourth of
1%.” He gives the following statistics on pneumonia following influenza
under drug medication. “Reports from 148 health commissioners show
an estimate (called conservative) of 33% of fatalities in epidemic
pneumonia under medical care. In some large centers it ran as high as
68% to 73%. As officially compiled to date, the fatalities in epidemic
=pneumonia= in our army and navy cantonment hospitals amounted to
34½. Osteopathy’s fatalities were only 10% which included all those
eleventh-hour appeals to Osteopathy.
“The Chicago and New York departments of health figures, each show
total death losses of 18% in all of their epidemic cases. Osteopathy’s
remarkable salvage of life is best measured from this point of
comparison. Its total death rate from both influenza and pneumonia has
been actually less than one percent.” And this is based on 110,000
cases reported to the American Osteopathic Association.
=Pathology.=—The pathology of Spanish influenza is practically a study
of lung involvement. There we find an exudative pneumonia of a rapidly
confluent type, a transudate of blood serum and red cells appearing in
the lower lobes of both lungs and rapidly flooding the entire space.
Air bubbles were scattered through the serum soaked lungs, giving a
frothy appearance to some parts. At times some parts of the lungs
showed drops of liquid pus.
Where pneumonia did not develop there was no typical pathology. The
toxins left an irritated bronchial tube, intestine or kidney just as in
any other severe toxemia.
Bronchial and the old type of lobar pneumonia also appeared as a
complication of Spanish influenza, making three types of pneumonia
which were to be guarded against.
=Symptoms.=—The attack is usually ushered in by a chill or prolonged
chilly sensations, sometimes lasting for two or three hours; fever 103°
to 105° F.; if it does not fall in three days or if it comes up after
once falling, pneumonia is to be suspected; pulse, full and bounding
with a varying rate; headache usually general in type and in severity
from slight discomfort to a most violent type; intense pain in the
back and legs; tenderness the whole length of the spine but especially
distressing in the upper dorsal, lower lumbar and sometimes the upper
cervical; a dyspnea which is best described as being a constricted
feeling of the chest with air hunger; often the bronchial tubes are raw
and dry, the patient feeling as if the breathed-in air were hot to the
bronchial tubes, an active exudative bronchitis developing; sometimes
there is an active bronchitis with distressing cough; nose bleed is a
frequent symptom (and is often a sign of threatening pneumonia); most
cases sweat more or less, some have drenching sweats; sleeplessness;
albuminuria frequent.
When the temperature breaks it practically always falls below normal
during the course of that day. A typical case of severe character often
presents all of the above symptoms; the lighter cases perhaps only two
or three of them, of which the chilly sensations, fever and bounding
pulse are the most common encountered.
A severe case is impossible to differentiate from the first symptoms
of smallpox. Where a case of this type is encountered, it is always
advisable to get history of vaccination or smallpox.
=Examination.=—The successful treatment of disease calls for attention
to little things. Some little thing properly cared for very often gives
us our margin over adverse conditions and spells success in the care of
our patient.
During the epidemic I found a few cases which ran a temperature much
below normal, sometimes as much as three or four degrees, and still
with enough symptoms to be easily diagnosed as influenza.
=Pulse= was taken at the time the thermometer was in the mouth. Pulse
was practically always bounding and hard. Its rate varied widely, being
influenced by many other conditions. I often, early in the attack and
where other symptoms were indefinite, made a diagnosis principally from
the pulse.
=Respiration= was taken while holding the watch and with the finger
on the pulse so that patient would not know that breathing was being
watched.
Many patients complained of a sensation of weight on the chest and
difficult breathing—hardly what one would term true =dyspnea= yet a
real air hunger and sensation of constriction in the chest. The breath
was often tainted with the odor of acetone, indicating a high degree of
acidosis and giving an important diagnostic point.
The =heart= was then examined, both by auscultation and percussion.
The examination was then extended over the lungs and pleural rub
listened for.
Patient was questioned as to having had a chill, general health,
occupation, undue exposure, fatigue, what physic if any, had been taken
or other drugs used, bowel movements and bloody stools, food taken,
sleep the night before, and dreams, headache and backache.
The full examination could not be given at each call and not all of
it to each patient, as time would not permit during the height of the
epidemic.
Throat was always examined. This is an important point.
The urine was examined in a great many cases and often albumin and
sometimes casts were found.
=Treatment.=—I consider it advisable to give a strong deep treatment if
the patient is seen before the attack has gained full headway; after
that I give short light treatments.
If the disease has not developed much at the time of the first visit
vigorous treatment with adjustment of the deep-lying and tightened-up
ligaments over the spinal cord is indicated. Subsequent treatments are
given to overcome the invariable and recurring contractions along the
spinal cord. The spine is gently sprung and the muscles pulled away
from the intervertebral foramina so that arteries, veins and nerves of
the spinal cord are free to function.
I might note here that I consider Spanish Influenza does its damage
through the attack of its peculiar and virulent toxin and the
accompanying acidosis, on the body’s reservoir of energy—the spinal
cord and related structures, the vegetative glands and nerves.
If the patient is in a serious condition he is often treated in the
position in which found, so as not to disturb him. Care is particularly
taken to keep a patient who is moist with sweat from taking cold
or being exposed. An extra covering is thrown across the neck and
shoulders, and pulled down as the bed covers are moved to get to the
area to be treated.
The musculature of the upper dorsal and cervical region is given
special attention, the region of the first and second cervical and
the first to sixth dorsal being special seats of trouble. The region
between the spine and scapula on the left side, first to sixth ribs
left, and the region of the suprascapular notch on the left side are
given specific treatment to free them of contractions. The tissues of
the suprascapular notch are in direct connection with the nerve supply
of the heart muscle and treatment here is astonishingly effective.
This treatment for the heart is best given with the patient lying on
the right side, leaning a little forward, with his left forearm against
the chest, hand at neck or chin. Stand then at the patient’s head and
with the thumbs give all the region on the left side at the base of the
neck and around the suprascapular notch thorough muscular adjustment
for circulation and removal of contractions which disturb the heart’s
vitality. Treat first to sixth dorsal region.
I consider this treatment specific for the heart debility of influenza
and many other heart conditions, as well. I have found it especially
effective in the weakened and nervous states following influenza and in
so-called “run down conditions” generally.
Vibration with the tips of the fingers on the anterior chest wall is
often used. Tender and contracted tissues are often found along the
anterior ends of the ribs which are involved at their spinal ends.
These are gently treated. Children are often given vibration, holding
their chests with my hands under their arms.
If the patient is stout and not easy to treat I have him sit up in bed
and give the upper dorsal thorough percussion with the side of the
hand[65]. About 100 strokes at each treatment are usually given. I
remember one very fat patient in the eighth month of pregnancy to whom
I could give hardly any other treatment. It was especially valuable
here and we saved the mother after a hard fight, though the child was
still-born.
When nature is meeting the emergency and holding her own in the battle
against infection we have a moderate fever—a benign fever. When the
body is overworked with other duties and irritations the fever may rise
dangerously high. Here it is that the physician must give further aid.
Here it is that osteopathic treatment further aids by giving rest to
the patient, easing pain and promoting general circulation (this in
itself often quickly reduces fever). Here it is that the attention we
give to clothing, diet, ventilation, quietness, good nursing, etc.,
comes in. The body is relieved of all duties but the one. Its functions
are all turned to one end—the destruction of the invading infection.
The osteopathic physician adjusts. Nature cures. It is all a matter of
adjustment.
For labored breathing, an effective treatment is to have the patient
with hands clasped and arms raised above the head, patient being in
bed, face up. Stand directly at head of patient. Reach over patient’s
arms and under the upper dorsal and lift up against the heads of the
ribs with your fingers, thus raising the chest, beginning as far down
the spine as you can and working up as you treat. Relax the muscles at
the same time.
=Frequency and Amount of Treatment.=—Frequency and extent of treatment
depend upon the condition of the patient. In influenza the patient is
approached with the idea of a daily visit. If then there is any doubt
about his being entirely safe for 24 hours he is seen in 12 hours or as
often as the condition indicates. Patients are usually seen more than
once a day.
The average time which the patients are confined to the bed is about
five days. Some are free from fever in three days; some not for six or
seven days. According to conditions they are then kept in bed from one
to three days longer.
As to the amount and length of treatment, I agree with James M. Fraser,
who says adjustment of the soft tissues should be made and made with
as little disturbance to the patient as possible. He says[66]: “The
ill effects of too long-drawn-out general treatments, or in short,
over-treatment, I consider one of the most important questions
for osteopaths because I incline to the belief that in many acute
infections more harm may be done by such fatiguing over-treating than
if the patient were really not treated at all. A “flu” or pneumonia
patient should never be treated over fifteen minutes at the longest in
one treatment. It is much better to treat often and not treat so long,
as over-treatment may result from a desire to be thorough. If we always
would stop and think what we are doing and just what we are trying to
prevent we would be more careful when we treat these infectious cases.
A patient’s resistance may really be lowered, his bowels inhibited, his
heart overstimulated, his muscles fatigued and his nerve force depleted
by treating overtime. When the reaction begins, stop.”
Congestions and contractions should be removed wherever they are found,
be it in the region of the throat, spine, ribs, liver or spleen. I
order a daily enema and give positive instructions—after having had one
or two almost fatal cases from this cause—to use no physics. Purging
killed more people here than any one other thing. If a heavy physic be
given two or three times and the patient comes to a crisis, so much
vitality has been taken out of the blood that he does not have enough
strength to carry him over and he dies.
If the patient comes to pneumonia I find it good and effective to use
the “constipation treatment.” It is best to let the bowel take care of
itself. Nature can do many things, and caring for the bowel in a crisis
is one of them, providing the correct diet has been given the patient.
If the patient is getting nothing but fruit juices there may be a
natural bowel movement and even if he has been getting other food it is
better to leave the bowel alone until after the crisis and then give
the enema.
A patient with a frank pneumonia following influenza has but little
chance of living if his strength is being drained from the blood stream
through the bowel every few hours.
I see to it that no draft blows on the patient’s bed. In a windy
location a cold draft can appear suddenly and do great damage in a
short time. The patient should not breathe cold air. Fresh air is all
right but it must not be cold air. I order extra covering for the neck,
arms, shoulders, back and chest. I like a wool workshirt best but use
pneumonia jackets, extra undershirts, sweaters, etc., when the wool
shirt is not to be had. In fact continued warmth seems to be an almost
necessary condition to the proper handling of influenza. It is because
heat, even the heat of the fever itself seems to aid the nervous system
in building up antitoxins.
The patient is instructed that if a sweat comes on, either from a hot
bath, hot drink or as a result of the disease, to lie and take it,
for throwing off the covers is a sure way of taking cold and inviting
pneumonia.
If the house is cold or the patient weak or very sick the urinal and
bed pan are used. In fact I prefer their use even when those conditions
are not present, as the less the exposure the less chance of pneumonia
and the quicker recovery. =Rest= lying in bed is absolutely necessary
to a satisfactory course and quick recovery.
For lung congestions and bronchial irritation, in addition to
osteopathic treatment along the spinal cord, raising the ribs and
chest, and vibration of the chest wall, I sometimes use the old
fashioned mustard plaster (made with one teaspoon each of flour and
mustard, mixed with olive oil or with water and white of egg), keeping
it on about ten to thirty minutes or until a good, red reaction is
brought about. The feet must be kept warm with hot water jugs. A hot
mustard foot bath is excellent when the feet persist in staying cold.
At first I did not use the hot tub-bath. I am now ordering it if I see
the patient early in the attack and where there is no contraindication,
such as a dangerous heart condition. I do not use it unless it can be
given properly and without undue exposure to the patient. I never give
it late in the disease.
A good method is to get the patient into the tub, lay two canes or
sticks across the tub, and cover all with a blanket or rug. Place a
bath towel for the head to rest on and pull the blanket around the
neck. The patient can then take a good hot sweat in comfort. His arms
and shoulders, his knees and legs will not be exposed to chill. When
he gets up the blanket can be drawn about him if desired. He then goes
back to bed for a good rest and sweat. A cold towel is placed on the
head and water given to drink.
Every patient should have a good sweat early in the attack. Another
good method is to cover with a blanket and place outside fruit jars or
jugs filled with hot water, cold towel to the head and several glasses
of water or lemonade to drink.
The use of cold compresses on the chest I do not favor. They are used
by some osteopathic physicians, but I believe the result is better with
other methods. Applied in a hospital where the technique is well in
hand they might be successful, but personally I fear them. I am even
careful about putting an ice bag on the heart. Cold packs are sometimes
used in my practice but only on the head for pain or delirium. Chill
must be avoided. Warmth must be conserved, even the fever is benign.
Neither do I favor “rub-on” of camphor, turpentine or onions when they
irritate the patient. If the patient has been used to them or has
faith in them and wants them I order them. I also order something of
the kind where “something must be done”. When a family calls a doctor
they “want something done,” and it is best to do something; ever
keeping in mind, however, that our patient’s strength must be conserved.
I do favor “rub-ons” in that I think it is well to keep the skin soft
with some oil. It helps to keep an even temperature and the skin
active. The skin should be wiped dry often, however, to remove the skin
secretions which if left on become stale.
I remember being called to see one little girl who could not get her
breath, and found she was holding her nose with the bed clothes. She
told me that the smell and stickiness of the lard and turpentine and
the onions made her so sick and uncomfortable that she felt she could
stand it no longer. When she was cleaned up, and clothed in nice clean
white cotton she showed a wonderful improvement, and it was real as
well as apparent.
As to =baths= in influenza, I instruct the nurse to bathe the patient
only as necessary for cleanliness and his comfort. Dabbling around in
water is not a safe procedure in a disease where pneumonia is so easily
contracted.
I do not use alcohol rubs where the patient is in anything like a
serious condition, as alcohol closes the pores and dries out the skin.
A rubbing or massage by the nurse is good for a restless, nervous
patient, but it had better be done with olive oil or some other good
oil. In influenza we do not want the pores closed. We need elimination,
and all we can get. A small saving of vitality or a little elimination
of toxins may be the margin that saves a patient for us. I do not favor
the use of turpentine, for if it is absorbed it irritates an already
sick kidney; if it is not absorbed it is useless. Why disturb the
patient?
For the bronchial irritation, in addition to osteopathic treatment,
and the accessory mustard plasters, inhalation of steam is often used.
A pan of boiling water is set by the bed and the patient leans over
the edge of the bed with a bed-sheet or paper over the head and steam
vessel, breathing the steam as long as it lasts.
For the =throat= most any cleansing gargle can be used but I prefer the
use of the common baking soda gargle. I have about one-half teaspoonful
of soda placed in a glass and boiling hot water poured over it. As soon
as this is cool enough to use I have the patient gargle thoroughly. The
idea is to get the mouth, pharynx and tonsillar area clean and free
from accumulations. Lemon-water gargle is often gratefully accepted.
If a very sick patient breathes through a dirty and dried-out mouth,
all the stage is set for him to draw into the devitalized lung large
quantities of infectious material. For this reason if not for the
comfort of the patient it is necessary that the mouth be kept clean and
also moist.
It is not possible to kill this germ life with any antiseptic. The
field must be made and kept clean.
The =nasal passage= also should be looked after, to keep it clean as
possible and also to allow the patient to breathe through the nose.
For the nasal passage any good non-irritating oil is effective but
I like best 2½ iodine in oil. It is a good lubricant and as far as
possible we do get the germicical action of the iodine.
Patients asking me what to do to avoid influenza are advised to keep
the mouth clean and closed and to use the oily solution of iodine in
the nasal passages.
And when treating the respiratory tract we must keep in mind the fact
that all healing comes from the blood side of a membrane. No healing
ever comes to a membrane from its exposed surface. Local treatment to
a membrane must be a treatment which removes irritation, not one which
adds more. Healing must come from within. “The rule of the artery is
supreme.”
=Diet.=—The diet used is liquid, so that the digestive functions will
be taxed as little as possible, for they are weak at this time. Fruit
and vegetable juices only are used.
The influenza germ propagates largely in the intestine and if the
intestine has in it the products of a full diet the bacterial growth
soon overpowers the patient. Germ life cannot develop on fruit and
vegetable juices.
Another reason for using the liquid and fruit diet is that influenza is
a disease running a short course and feeding is not necessary. If it
were a disease such as typhoid, running a fever for several weeks, we
would then give a more liberal diet, but the patient’s strength will
not be lost on a liquid and fruit-juice diet in three or even eight
days.
The frequency with which the urine contains albumin in this disease
shows us what a heavy load the kidneys are carrying. This makes a
salt-free diet advisable and again brings fruit juice to our favorable
attention.
To activate the kidneys and thus relieve the headache we give always
plenty of water and often hot lemonade. Orange juice and lemonade are
used frequently as are blackberry, raspberry, pineapple, loganberry and
grape juices. When the acid juices are not well borne we use non-acid
juices, such as pear and raspberry juice. A ripe, cooked pear mashed
with a fork and mixed with one or two different fruit juices makes a
satisfying dish.
Bottled sweet cider is also a most valuable food and a good beverage.
We use it in almost every case and find it the most acceptable to the
patient of any food offered. I am of the opinion that apple cider has
been neglected as an article of diet, both in disease and health, but
especially in fevers. It contains considerable iron for the blood, as
well as having considerable food value. It has the added virtue of
being pleasing to the patient.
In addition to these juices we often use spinach juice. I have the
nurse get a can of the best grade spinach and serve the juice hot, as
a broth, with a little salt and pepper and perhaps celery salt and a
piece of bacon in it to flavor it and to appeal to the patient. Spinach
juice contains much iron and iodine in a form readily absorbable by the
blood. It also is useful in maintaining the alkalinity of the blood and
body fluids, thus counteracting the acidosis of the disease. It renders
the urine alkaline and thus relieves the kidneys of the irritation of
acidosis and of an acid urine. Where the kidneys are or are likely to
be involved the spinach juice must be served without salt.
All the mentioned fruit juices tend to counteract acidosis and produce
alkalinity, but are not so effective as the spinach juice. They have
the advantage, however, of being used in larger quantities. The spinach
juice has considerable food value and has the added value of appealing
to the patient’s reason, when the iron and iodine content is explained
to him. It is especially useful when treating those patients who are
wondering if they should not be getting some sort of “tonic.”
The juice taken from ground fresh lettuce is also valuable. It contains
more iron, iodine and phosphates than the spinach but it is not so easy
to prepare. I have used it in the cases of several anemic and quite
sick babies and consider it well worth all the expense and effort it
took to secure it.
The breaking down of the alkaline reserve of the body and the
consequent acidosis, comes early in the disease and is disastrous, and
all the attention given to the diet is amply repaid in results. Careful
attention to the diet is the only way the acidosis can be overcome.
Raw fruit and vegetable juices also supply that most valuable element,
vitamines. For this one thing alone is the raw fruit juice most
valuable. I do not believe too much attention can be given to securing
a liberal supply of vitamines for the body, especially during an attack
of fever.
Some especially interesting points are brought out by contributors
to the Journal of the American Osteopathic Association in the March,
1919 number. I wish here to add a discussion of these points. The
contributors are physicians and good representatives of our profession
and they report uniform and excellent success in handling the recent
epidemic.
It seems to be the consensus of opinion that the treatment should be
specific and light to avoid fatigue, with the possible exception of the
first treatment, which often should be general and vigorous.
All are agreed that the patient should be kept in bed, not even leaving
it to go to the bath room. The patient must be protected in every
way from fatigue and exposure. The enema was used by all. A number
of writers state plainly their opposition to the use of physics and
laxatives. A hot tub-bath is recommended by several, but there is
opposition to much bathing.
Practically all the writers used the fruit-juice diet. However, a few
gave a heavier diet and were successful with their patients, which is
one more proof that the osteopathic treatment is the deciding factor in
bringing about a cure.
J. R. Thornton wrote after having had about 100 cases. He speaks
especially of his cases of pneumonia. They resolved by crisis.
There were no deaths. He says: “All cases were, preceding the first
treatment, given a generous plain water enema. Orders were left for two
enemas per day until told to discontinue, and in most cases the patient
got the enema. A few cases, with the highest fever, the stationary
fever, were given tap-water enemas, one each hour until the temperature
dropped two or three degrees.
“Sponge baths were given to reduce fever in every case. Diet was liquid
until the temperature was normal.
“The osteopathic treatment of the usual spinal work, paying special
attention to cervical and dorsal areas, and strong inhibition.
“Pneumonia cases were treated three to five times a day and had as much
time as they required at each visit. They required action. Heating
compresses were used on each case, except the ice bag to the heart
when rapid. One case of delirium was treated with ice caps to the head
and neck. Normal salt solution per rectum. Murphy drip was given in
each case. Diet, liquid consisting of egg-nog, milk, strained soup and
broth.”
Mary Alexander Patton: “Treatment should be quick, every motion
significant so as not to tire the patient, for exhaustion is always
present. Each patient was treated two or three times a day until
temperature became normal. The nasal douche was given twice a day
followed by K-Y jelly. Hot soap bath followed by soap enema and
enteroclysis when fever persisted.”
W. Curtis Brigham ordered “Hot packs the full length of the spine
twenty to thirty minutes, three times a day. This will produce profuse
sweating and often put the patient to sleep.”
I have used this same treatment, especially in nervous cases, and hold
it in high esteem. I have the patient put a bath robe on backwards
so that the arms and legs are well protected but the spine easily
accessible. The hot packs can then be used and covered over and the
patient not exposed.
R. H. Nuckles maintains that lung and ear trouble will not follow
influenza where osteopathic treatment has been given to adjust the
cervical and upper dorsal circulation.
H. A. Price: “We have kept particularly in mind, first, the nerve,
blood and lymphatic supply to the lungs; second, the circulation to the
spine (meaning spinal cord); third, the internal secretory functions
and to the general excretion.”
Ralph M. Crane says: “A great deal of my work is among the Italians. It
was necessary to give quick specific treatment that I might do as much
good as possible to the greatest number. I did not treat them as often
as I would like to, and because of this fact I learned that osteopathy
got control of the ‘flu’ immediately, the first treatment sufficing to
start them on the road to recovery; in fact, many of them got no more
than one treatment.”