By JAMES I. JOHNSTON, M. D.
The history of epidemic influenza extends back with definite
authenticity to the Middle Ages, with a fair amount of assurance to the
beginning of the Christian Era and with presumptive reliability even
before that period. Beyond this statement, nothing definite can be said
until the first epidemic reported by Short and found in the English
Annals in the year 1510. This, the first reliable record, presented some
features not unlike those occurring in the present epidemic. Two or
three striking things stand out in this record—namely, the presence of
nose bleed, pneumonia and the very great danger to gravid women. Here,
for the first time, the meteorological conditions were elaborately
studied and persistently dwelt upon. One other impressive thing, also
reported by Short, was that in 1580 the disease showed a tendency to
return after a period of quiescence. Attention is called to this because
the epidemic, while it was exceedingly prevalent in the months of August
and September, became pandemic in October and November. Another feature
was that during the years intervening between 1580 and 1658 sporadic
cases of this disease were frequently reported. During the latter year
another epidemic appeared in the month of April. In 1657 and 1658 at
London the summer was very warm, the winter came on early, there was
much snow and the spring was very moist.
The prevailing opinion at this time, and the first stated by Willis, was
that the widespread disease was due to the weather influences on the
circulation, poisoning the blood of the patients, and “not blasts of
malignant air.” The disease prevailed in the large cities, recurring
again in the autumn in an extensive form through the villages and
country. Sydenham, in his communication on the epidemic in 1675, wrote
emphatically on the influence of the infection on pregnant women, and
here used the term “tussis epidemicus” as a name for the disease. The
summer of 1675 was wet with an inconstant autumn. La Grippe prevailed in
France and Germany, according to Atmuller. In England in 1676, the
autumn was pleasant, but suddenly became cold and moist. La Grippe then
started in Germany during September after a summer and a beginning
autumn which was very rainy. Molyneux in his description of the epidemic
of 1693 in Dublin called attention to a feature, very striking to the
recent pandemic, that the aged to a great extent escaped the infection.
This would seem a somewhat unique feature until that epidemic is
compared with the present one. In 1729 Morgagni and others stated that
over all Europe the winter of 1728 was very rigorous, the spring was
cold and the summer and autumn very variable, while January and February
of that year were very moist. Huxham in his record of 1729, the fifth
extensive one on record in the English Annals, which extended into 1733,
stated from his study at Plymouth that the epidemic was exceedingly mild
in the year 1733, and, with the exception of infants and consumptive old
people, the mortality was very low. Like many of his predecessors, he
emphasized greatly the conditions of the weather at the time and
presented an elaborate study of it. The epidemic of 1732 was one of the
longest and most persistent, extending up to 1737. All authors do not
hesitate to attribute as a cause the very frequent variations of
temperature which characterized this period. Of this epidemic Arbuthnot
also emphasized the importance of the air, assigning the prevalence and
widespread features of the disease to the thick and frequent fogs. From
November, 1732, until March, 1733, this disease spread from Germany to
Italy and thence to England. He called attention to a very striking
feature—namely, that people in prisons and in hospitals escaped the
disease. This, as we know, where such institutions are placed under
preventive quarantine, is not such a unique feature during this present
scourge. He, more than former writers, devoted pages to the elaborate
and accurate description of instruments for meteorological observation
and their findings, which meteorological records were published in
detail, covering the whole period of a year—June, 1732, to June,
1733—with almost daily regularity. Huxham in 1737 in his record first
used the term “epidemic catarrhal fever”—a name often used subsequently
to describe this disease. Here attention was first called to the
prostration which characterized the convalescents, and his belief that
consumption frequently followed the disease. The next epidemic, which
occurred in 1742 and 1743, was also reported by Huxham, who stated that
the weather was very rigorous. This disease, according to his
description, extended over all Europe, and the term “influenza” seems to
have been first used by him during this time. The cases were mild in
England, but more severe in Southern Europe. Whytt in his record of the
epidemic of 1758 was the first who did not consider that the air
condition or the seasons had the significance attributed to them by
former writers, since the weather conditions during the prevalence of
the disease were generally mild and dry. In Edinburgh at this time not
even one out of seven escaped. Nevertheless, he did not hesitate to
express his opinion that the disease did not spread by contagion from
one person to another. One other observation of his is worthy of note,
which is: that frequent relapses occurred when patients were re-exposed
too soon after the first infection and such relapses were much more
severe than the original disease.
The epidemic of 1762 called forth the opinion of Baker, emphasizing an
opinion already expressed by Whytt, that the origin of epidemic disease
is not due to changeable winds nor to their nature or character as
recorded by the barometer. This epidemic also prevailed over all Europe
and appears to have begun following sharp alterations of cold and
moisture. In 1766 in Spain, France and other parts of Europe the
epidemic appears to have begun after a warm summer, followed by an
autumn moist and cold. In 1767 Heberden placed on record his
observations during this period, but nothing new was reported. In 1775
the disease began in Germany in the summer after a dry and warm spring
and spread over all Europe. During the prevalence of the disease in 1775
a questionnaire was sent to the leading English physicians, and letters
from Fothergill, Sir John Pringle, Heberden, Reynolds and others seemed
to express a consensus of opinion that weather conditions had nothing to
do with the prevalence or spread of the disease, and that the cause and
reason for its spread were unknown. Following sharp alterations in
temperature in 1780, the disease appeared in France and then throughout
the world. The epidemic of 1782 began in Russia, starting January 2 at
St. Petersburg. The thermometer underwent a variation of 40 degrees and
the same day 4,000 were afflicted with La Grippe. It reached Koenigsburg
in March, Copenhagen in April, London in May, France in June and July,
Italy in July and August, Spain and Portugal in August and September,
and then reached America. Edward Gray, writing of the epidemic of 1782
for the first time, expressed emphatically his opinion on the
contagiousness of the disease and stated what we now know—that close
contact is necessary. To him also is attributed the opinion first
mentioned by him, that there is a possibility of carriers in this
disease. During this time Dr. Hamilton, in a published letter, protested
against venesection in influenza, a practice long prevalent, and Hogarth
called attention to the fact that the disease began in cities and
villages first and that it was brought to these places by visitors from
without.
The first American writer on this subject was Noah Webster in 1647 and
1655. Following him was Warren, writing of the epidemic of 1789 and
1790, just 100 years before the last and greatest epidemic which
preceded the present one. Rush and Drake also reported this epidemic.
During that epidemic which prevailed in America from September to
December, 1789, and appeared again in the spring of 1790, President
Washington suffered a very severe attack. The year before, in 1788, when
the epidemic prevailed abroad, the summer temperature in Paris was very
variable, variations of 8, 10 and 12 degrees occurring on various days.
La Grippe predominated all the time. The same variations were true in
Vienna. At the end of the year 1799 the epidemic struck Russia,
following very cloudy, misty weather, was prevalent in Lithuania in
January of the year 1800 and in Poland during February.
The next great epidemic occurred in 1802 and 1803, was very general,
beginning in France and coinciding with a cold and moist autumn
following a very dry summer. It was of six months’ duration in England.
Many schools, jails, asylums and workhouses, although located in the
area swept by this plague, at first escaped. As mentioned before, this
striking feature has not been so unique in subsequent epidemics. One
feature noticed here and commented upon freely was that elsewhere
throughout the country there seemed to arise endemic foci. During this
time there was also the prevailing belief that the disease was followed
by phthisis. One other observation made here, which was accurate,
lasting and is accepted today, was that no family was affected _en
masse_, but always one individual case occurred first, to be followed by
general infection of the others. At this time early bleeding was still
adhered to. The French spoke of seven varieties of the disease, but one
can only see in the classification emphasis laid on certain individual
symptoms in this disease of complex symptomatology. During this epidemic
pneumonia is said to have been very infrequent. The disease was
particularly fatal to pregnant women, and the patients suffering from
pulmonary tuberculosis were hurried off by the influenza.
Burns, writing of the epidemic of 1831, mentioned that in 1810 the
disease was very widespread in China and Manila, and also emphasized the
fact mentioned in many works that certain epidemics prevailed among
animals at the same time, stating that in 1831 these diseases were of
choleric nature. This epidemic began in 1830 in the East, reached Paris
in the summer of 1831, reappeared in Europe in 1833, following the same
route that cholera had taken in 1832. In the epidemic of 1833, Hingeston
also laid great stress on the fact that horses were often affected.
These features, as mentioned by Burns and Hingeston, are frequently
quoted by authors, and such observations seem to have been widely
accepted.
One of the greatest epidemics of influenza began in 1836 and extended
until 1837, and was called at this time epidemic catarrh. It began in
England in January, spread to France, and during all the time that it
was in Paris there were continual penetrating rains with cold and
humidity. At Montpelier on February 20, 1837, the thermometer passed
from 12 to 15 degrees above to 2 and 3 degrees below zero, and it was
then that La Grippe appeared suddenly. In reply to the circular letter
sent out by the Council of the Provincial Medical Association of
England, comprising 18 questions, the following opinions prevailed. The
disease was greatest from September to February; the great prevalence of
the epidemic in all parts of the kingdom was recognized—attacks were
irrespective of age, sex or temperament; it was milder in children, and
the aged suffered most from it. Further, the disease was extensive in
all neighborhoods; the mortality was 1 in 50, old age predisposed to
fatal termination, and the duration of the disease occupied two periods,
one terminating in 4 or 5 days and one in 5 to 14 days. Also relapses
were frequent; those exposed to employment in the open air were not more
liable to the disease than others; there was no proof of the disease
being communicated from one person to another, and influenza aggravated
an existent pneumonia or pulmonary phthisis. And finally previous
attacks of influenza offered no protection; the symptoms were uniform;
the most common of unusual symptoms were those of meningitis,
inflammation of the lungs and syncope, and aside from ordinary care and
treatment, general venesection was not endorsed. Evidence of fine
weather and good telluric conditions were at this time also appended.
The same symptoms and complications, particularly those of the lungs,
occurred irrespective of seasons, civilization or place. It was believed
and stated that the plague described in Homer was probably influenza.
For the first time there is noticed here a point well worth
consideration—the association of other epidemics with influenza, either
anticipating, following or superseding. That some such association may
follow the present pandemic is not to be entirely ignored. For example,
cholera is already reported as prevailing abroad, following an earlier
influenza outbreak. During the period, as if anticipating bacteriology,
one writer explained the epidemic in an article called “The Dust of
Regular Winds,” and Groves (1850) wrote on “Epidemics Examined, or
Living Germs as a Source of Disease.”
In 1846 and 1847 a slight epidemic occurred in London, Paris, Nancy and
Geneva. In France during the last week of 1857, and extending into
January and February, 1858, there was a mild epidemic. During this
period there alternated frequent frosts with soft weather, misty and
humid. Among the numerous small epidemics between 1837 and 1889, one
occurred on the continent of Europe in 1860, but little of value or
interest was noted. In Paris in March, after great and sharp variations
in temperature, a series of epidemics extended from 1870 to 1875. These
were unimportant. Atmospheric modifications occupied first rank in the
minds of some as a cause for the outbreaks. Rapid changes from hot to
cold or from cold to hot were given weight. Other undetermined
modifications of conditions were probably important.
In a recent article published by Loy McAfee (J. A. M. A., 1917, 72, 445)
he discussed the confusion which existed between the diagnosis of
cerebro-spinal meningitis and epidemic influenza in 1863. These were
believed the same by some—that is, the same disease of varying degree.
There was a great diversity of opinion among clinicians at this time,
and the American Medical Association appointed a committee to make an
investigation. McAfee quotes from the Medical and Surgical History of
the War of the Rebellion that in 1861 and 1862 an epidemic existed among
the troops called epidemic catarrh, which was afterward changed to read
acute bronchitis. In September, 1861, there existed an epidemic of
influenza in one of the regiments which lasted more than two weeks, and
in another camp there was a similar epidemic at the same time. It is
stated that there were in all 168,715 cases among the white troops, with
a mortality of 650, and 22,648 among the negro troops, with a mortality
of 255, making about 4 per thousand, and over 11 per thousand,
respectively.
The next great epidemic, and the last until the present, occurred in the
years 1889 and 1892, and was pandemic in its nature. The death rate
during this time was lower in the cities than in the country. This was
probably due to the fact that the greatest mortality was among children
and old people, and as old people were generally left in the country,
this explains the observation. The highest number of deaths was among
males, believed to be due to the exposure and fatigue of work. Forty per
cent. of the world’s population was said to have been attacked during
this period. The yearly or seasonal repetition, as shown in this
pandemic, had occurred in other epidemics. In the great pandemic of 1889
and 1890, five decades after the last important epidemic, it was stated
that the medical profession found itself confronted by a new disease of
which it had knowledge through medical history, so also in our time few
physicians recognized at first the reappearance of influenza. This 1889
epidemic is extensively reported in the literature, and has been
elaborately worked out by many observers. One important feature has been
emphasized by Leichtenstern, which, although recognized by the
profession after the last epidemic had been fully reported and recorded,
is not appreciated by the profession during the present epidemic—namely,
that while shortly after the last epidemic there were smaller
relightings of the infection throughout various parts of the country,
those diseases which we erroneously call grippe or influenza, occurring
commonly in the spring and fall, are in no way connected with the
disease with which we are dealing, and which occurs at rather long
intervals. Any speculation in regard to these periods, which history has
shown to be fairly wide apart, has very little basis. This pandemic,
like many of former days, is believed to have originated in Asia, and
from there to have spread over Europe and hence over the world. The
disease spread rapidly over countries, affected probably about 40 per
cent. of the world’s population, disappeared rapidly after several
weeks, was thought to have had nothing to do with weather conditions,
had a great morbidity but small mortality, and affected all ages and
occupations. There is no doubt, as stated by some, that the development
of traffic and travel was a large factor in the rapid and extensive
spread of influenza during this pandemic. The course which the disease
followed, springing from its supposed beginning in Asia, has been fully
and amply described by writers after that period, but the great rapidity
of its dissemination over all countries is the most remarkable feature
in the epidemiology of any disease. This, during 1889, made many
prominent physicians disregard the opinion that influenza spread by
contagion and accept again the opinion expressed by observers of
epidemics in former ages, that miasma as a pathogenic agent was
responsible for its distribution; but anyone who reads closely the
history of this epidemic, and in the light of modern medical science,
must feel that the rapidity of distribution was nowhere greater than the
most speedy means of transportation. This very necessary close
connection was demonstrated also in regard to the mode of spread of the
disease; the large cities and the commercial centers were affected
earlier, smaller and country districts followed later, railroad towns
were more frequently attacked than isolated villages, and even from
jails, prisons and workhouses, where quarantine was immediately
attempted, as well as from remote villages where the disease had been
brought, there could be traced a zone of infection spreading into the
country. One interesting point was raised at this time—namely, that in
some places it seemed to spread by leaps and bounds, and at other places
radiating as stated above.
The old controversy of whether influenza is distributed in a radiating
manner or in so-called leaps and bounds is believed to be settled by
consensus of opinion that it occurs in both ways. An opinion expressed
by the study at this time as to whether influenza spreads more rapidly
than any other infectious disease is found in the statement that the
contagion is markedly virulent, the micro-organisms are easily conveyed
from their original seat in the mucous membrane by coughing, sneezing
and expectoration, the great number of persons who, though slightly
affected, carried on their ordinary way of life without hindrance, the
probable longevity of the organisms in convalescents, the brief period
of incubation of two or three days, the susceptibility of all people of
every age and vocation, and the possibility of carrying the contagion by
merchandise and even through short distances in the air, are all
suggestive reasons for this. No one at present accepts the so-called
miasmatic nature of the contagion. Proofs are ample to show that one
case must be present in a locality or even family, although it may be
frequently overlooked, from which the epidemic spreads. During this
period of 1889 and 1890 the duration of the actual epidemic period in
different localities in Europe was from four to six weeks. This was
subsequently shown to be consistent with the recorded reports from the
various cities in the United States. Following this pandemic in the
first part of the year in 1891 there were numerous epidemic outbreaks in
various parts of America, including New Orleans, Chicago, Boston, and
simultaneously in England. Strange to say, at this time neither Germany
nor France had such epidemics, although both were exposed by travelers,
particularly from England and America. The question was raised at that
time whether the Germans, French or other continental nations were more
immune than Americans and English. In the fall of 1891 and the entire
winter of 1892 the disease was extensively prevalent both in Europe and
Northern America. In these later epidemics there was no definite
direction of spread. They probably would come more clearly under the
so-called radiation from numerous rural districts. In almost every case
at the point of its origin in these countries the epidemic developed and
spread slowly, lasting months and with very varying morbidity and
mortality. They had none of the explosive characteristics of the
pandemic. The general diminished morbidity of the later epidemic, the
diminished geographic distribution of the disease and the scarcely
recognizable character of its contagion, its slow development and
extension over several months, the continuous diminution in frequency
and in intensity since its onset in 1889, have been explained by
presumptive successive lessening of susceptibility of the population,
possibly due to acquired immunization. Observers at that time, as well
as ourselves, could question this last statement.
There was observed one noteworthy thing about seasons. While the great
pandemic of 1889 and 1890 had no definite connection with seasons, the
epidemic types which followed in 1891 and 1892 seemed to show a lighting
up in either spring or fall, remaining dormant in the summer months. It
has also been shown by the history of former epidemics that almost all
the pandemics started from Russia in the fall, winter and spring months.
Such was the case in 10 of the great pandemics of 1729 to 1889. This, no
doubt, was the reason so many of the former historical writers were
impressed by seasons and meteorological conditions. The statement made
by observers during the epidemic that influenza presented two phases,
one pandemic and the other endemic, and that each follows different
epidemiological rules, seems possible. The question raised during the
last epidemic of the spread of the disease in families, the disease
occurring at high altitudes and even at sea, we know does not interfere
with the recognition of its spread by direct contagion. Definite
examples of families or villages being infected by a returned member of
such family or citizen from abroad are reported frequently, and even the
appearance of the disease in isolated places has often been traced and
verified from a definite source, to say nothing of the question of
carriers and those supposed to be suffering from other diseases.
Striking examples are shown also in this epidemic that many
institutions, frequently those isolated from the world, were markedly
exempt until, through servants or outside visitors, the disease gained
access to them. This gave a most favorable field for the study of
invasion, spread and decline of the disease. Observations made at this
time in regard to hospitals seemed to suggest that certain institutions
were more or less exempt, although not closed institutions, while others
suffered from the first. These two types of hospital invasion are hard
to reconcile.
Great stress was laid in this epidemic upon the very great morbidity and
the low mortality. Simple, uncomplicated influenza at this time was
looked upon as a disease that was rarely dangerous to life. Studies have
shown that after this period there seemed to have been lessened
morbidity. As previously stated, nearly all the numerous pandemics at
various times have had their origin in Russia and arose in the late
autumn or winter months. This pandemic of 1889 and the succeeding severe
epidemics in Europe and North America in the years of 1891 and 1892
occurred almost exclusively in the cold weather, the summer remaining
free. It is generally believed now, and was at the end of that pandemic,
that atmospheric or telluric conditions had nothing to do with the
spread. The origin of epidemics following the pandemics seemed to be
influenced in their recurrence by the season of the year. It was
conceded by observers in that pandemic also that contagion might be
carried by merchandise and even flies and healthy individuals.
_1918 Epidemic in Large Cities_
In the city of Boston during the week ending August 28, at the Naval
Station at the Commonwealth Pier, 50 cases of influenza occurred and
within the next two weeks more than 2,000 were reported in the naval
forces of the First Naval District. Of these 5 per cent. developed
broncho-pneumonia with a mortality of more than 60 per cent. From here
it probably spread to Camp Devens and thence ran rapidly over the
country. There can hardly be a question that it spread along the lines
of traffic. Up to November 9 there were reported 3,339 cases among the
civilian population of Boston. There were 3,430 deaths from influenza,
the presumption being that these were due to bronchial pneumonia,
although not reported as such. The deaths from all forms of pneumonia
were reported as 942, making in all 4,372 deaths from September 7 to
November 9. This discrepancy—that is more deaths than reported cases of
influenza—is due to the fact that influenza was not made a reportable
disease until the date of October 4, fully a month from the time the
epidemic appeared. The weather conditions were generally fair and no
noted abnormality is recorded as compared with other years. The
statement of the Health Department of this city was that, after a
practical disappearance of influenza in October, there was a slight
recurrence in November and a more pronounced recurrence about the first
of December, since which time the cases have slowly but steadily
decreased, until at present—December 21—the fatalities attributable to
influenza are about 20 daily.
In the city of New York the epidemic first appeared September 18. Up to
and including December 27 there were reported to the Department of
Health 136,061 cases of influenza and 21,388 cases of pneumonia. The
number of deaths since September 18 was 11,725 attributed to influenza
in the death certificates filed in the Health Department and 11,601
attributed to pneumonia. The epidemic reached its peak during the week
of October 19, slowly subsided and was practically at an end on November
9. While the epidemic is reported as ending on this date, the mortality
rate from influenza and pneumonia is still very much above normal. No
particular features concerning the meteorological conditions were noted,
except that in this city the weather was clear and delightful during the
months of September and October when the epidemic was rampant.
In the city of Philadelphia on July 22 the Health Department issued its
first health bulletin on so-called Spanish influenza, announcing the
possible spread of this disease into the United States. On September 18
a warning was issued against an epidemic, the department starting a
public campaign against coughing, sneezing and spitting. On September 21
the Bureau of Health made influenza a reportable disease. At this time
the authorities stated an epidemic of influenza was recognized as
existing among the civil population of similar type to that found in the
naval stations and cantonments; that a large percentage of cases was
accompanied by pneumonia; that patients should be isolated and
attendants wear masks; that isolation be practiced for a period of ten
days after recovery to prevent carriers; that patients be guarded
against relapse and that the public be cautioned against large
assemblages and crowded places, as well as to avoid coughing, sneezing
and spitting. On October 3 the churches, saloons and theatres were
closed, funerals were made private and food handlers were required to
protect their wares. The number of cases reported from September 23 to
November 8 was 48,131, but the Bureau states, from a rough estimate, the
number of cases was probably 150,000. The total number of deaths
reported was 7,915 from influenza and 4,772 from pneumonia in all its
forms, the presumption being that the deaths during this period were due
to influenzal pneumonia. The weather condition during this time is
recorded as mild and fair.
The influenza cases began to be reported in Cleveland on October 5, and
up to December 20, 22,703 cases had been recorded. Certificates
recording deaths due to influenza alone numbered 2,497, while pneumonia
amounted to 833. The epidemic was at its height in the latter half of
October and the weather was spoken of as pleasant fall weather. During
the week of October 26 the epidemic reached its greatest height, abated
in the week ending November 23, increased later, but showed a drop for
the week ending December 21.
The epidemic first reached Chicago on September 21, and from that date
on it rapidly increased throughout the city for a period of 26 days
until October 17, when it reached its maximum both in the number of
deaths from influenza and from pneumonia. On that day the total number
of deaths from influenza and from pneumonia reported was 2,395. From
September 21 until November 16 there were reported 37,921 cases of
influenza and 13,109 cases of pneumonia. On September 8 at the Great
Lakes Naval Training Station, which is 32 miles north of the city, an
extensive outbreak of influenza occurred. This was 13 days before the
outbreak in the city of Chicago itself. Camp Grant, located at Rockford,
92 miles northwest of the city, suffered an outbreak on September 21. A
suggestion of the likelihood that influenza was prevalent in this
country in a mild and unrecognized form in the spring of this year is
shown by the fact that numerous local outbreaks of acute respiratory
diseases were brought to the attention of the Health Department of
Chicago. These occurred especially in large office buildings and in
industrial departments. The total number of deaths from influenza and
pneumonia during 14 weeks was 51,915. This would indicate that a very
great number of cases were not reported to the Bureau of Health until
they died or else there must have been a large number of deaths due to
lobar pneumonia. One naturally obtains from these figures the impression
that the disease was not recognized for a long time, that the pneumonia
must have been called lobar pneumonia, and that the actual figures
gathered by this city, as well as others, must have been greatly
confused at the onset of the epidemic. It is not unlikely that records
from many of the army cantonments and naval stations may be considered
from the same viewpoint. Weather conditions were considered normal at
the height of the epidemic, the weather being dry. There has been a
flare-up of influenza recently, but not in sufficient numbers to justify
calling it epidemic.
In the city of Louisville, Ky., the epidemic started September 26, and
the total number of cases up to December 21 is reported as being 9,445.
Out of this number 772 deaths occurred from pneumonia. No distinction is
made here between broncho-pneumonia and lobar pneumonia, but the
presumption from the records of other cities at this time is that these
were cases of broncho-pneumonia following influenza. The weather was
described as being delightful fall weather. The statement is made by the
authorities that while the epidemic is still prevalent, it is confined
largely to children and is rapidly abating.
The first case in the city of St. Louis was reported about October 7,
and up to December 23 there had been 31,531 cases reported to the Bureau
of Health. They recorded 1,920 deaths with influenza given as a
contributing cause. Preceding the time when the epidemic was at its
height the weather was fair and warm, and the statement is made that,
“without going into the matter exactly, we have been of the opinion that
damp, rainy weather has been a help in controlling the disease.” The
opinion was expressed by the Commissioner of Health that the disease had
now abated.
No information could be obtained as to when the epidemic first reached
the city of New Orleans, but during the months of October and November
43,954 cases of influenza were recorded. Of this number 2,188 died from
a combination of influenza and pneumonia. They stated in their health
report that during the period from January 1 to December 31 there were
239 deaths attributable to broncho-pneumonia. The weather was mild and
on December 24 the epidemic was stated to have abated.
The city of Minneapolis recorded its first case on October 7, but the
authorities expressed their belief that a few cases had appeared before
that date. Up to December 21, 15,000 cases had been reported to the
Bureau of Health and of these there had been 735 deaths from
broncho-pneumonia. They had in their city a late, rainy fall and up to
that period they had had no cold weather.
The record obtained from the city of San Francisco stated that the
epidemic first appeared September 23 and that it was very widespread in
that city early in October. There were two invasions and 53,260 cases
reported. At the height of the epidemic more than 2,000 cases were
reported in one week; 188 deaths occurred from influenzal pneumonia. The
following week, after the institution of mask wearing, in which between
80 and 90 per cent. of the population concurred, it was stated that the
number of cases decreased to about 200. It was stated that the weather
was generally very fair during the epidemic.
From the city of Portland, Oregon, the following information was
obtained: The epidemic first appeared October 11, with a second one
toward the end of the year. There were 8,079 cases reported, with 658
deaths from influenza and 250 from pneumonia. Weather conditions were
stated to be varied, but the health officer believed that during the
worst wave the weather was clear and dry, with easterly wind. He
believed that a decrease in influenza was noticed immediately after a
Chinook wind and warm rain. Similar observations were made by Coutant in
Manila.
A weather comparison of 12 large cities, well distributed over the
United States, studied during this pandemic of influenza and checked
with normal weather during that of many years, shows: Boston, fair with
no abnormality; New York, clear and delightful, no abnormality;
Philadelphia, mild and fair; Pittsburgh, mild and cloudy; Cleveland,
pleasant fall weather; Chicago, normal and dry; Louisville, delightful
fall weather; St. Louis, fair and warm-damp, rainy weather later seemed
to control the epidemic; New Orleans, mild; Minneapolis, a rainy fall
and no cold weather, which is unusual there; San Francisco, generally
fair, and Portland, Oregon, clear and dry.
_The Epidemic in Universities and Colleges_
At Bryn Mawr College, in Pennsylvania, an institution devoted to the
higher education of women, located within 10 miles of the city of
Philadelphia, the epidemic occurred at the beginning of the college
year—October 1. This college at the time had an enrollment of 465
students. There were 85 cases of influenza, with an additional 25 who
suffered from influenza in their homes. There were no deaths from
pneumonia. The weather conditions were clear and warm, and since
November 29 there have been no new cases occurring in the college and
only three or four of the students have been ill at their homes since
that time.
[Illustration:
DATES OF THE APPEARANCE OF INFLUENZA ENDEMIC IN VARIOUS CITIES OF THE
UNITED STATES
1918.
]
The enrollment at Smith College, Northampton, Mass., was 2,103, and the
first case of influenza appeared with the arrival of the students on
September 18 and reached its height on September 30. All group
gatherings indoors were stopped from October 3 to October 18, and the
epidemic was over by October 20. A recurrence began November 15 and
continued until December 17. There were 182 cases in the first epidemic
and 100 cases in the second. There were only two deaths from influenza
pneumonia. During the rise of the epidemic the weather was rainy,
followed by good, clear weather. The change in weather conditions seemed
to make no difference. The second epidemic was still prevalent when the
students left for their holidays.
In Wellesley College, where there were enrolled 1,593 students, the
epidemic first appeared on September 18. Up to the middle of December
they had had 280 cases. During six weeks of the epidemic 265 cases were
reported and only one death occurred from broncho-pneumonia. For the
most part, bright and sunny days were present, with only a few cloudy
and rainy days. This college has not been without cases since September,
but the epidemic lasted only about six weeks.
In a communication from Columbia University it is stated that the
epidemic appeared during the week beginning September 22. No records
were available for the student body at the time of inquiry, but in the
Student Army Training Corps of 2,200 men between 8 and 9 per cent. had
the disease during the period from October 1 to December 14. In this
army group during this period two deaths from influenza and pneumonia
occurred. The weather conditions in the city during this time were
considered normal for fall weather—that is, mostly clear, with high
winds. The opinion expressed was that the epidemic was still prevalent
and increasing, and that a return wave seemed to be more virulent and
affected the children of the city more than had the first one in the
early fall.
There were enrolled at Harvard on October 1, 3,193 students. The first
case of influenza occurred on September 20. There were 227 cases of
influenza reported; of these there were 46 cases of broncho-pneumonia,
with five deaths. There were two waves to the epidemic; the first wave
height was in October and the second the last of November. The weather
conditions were not severe nor particularly unfavorable at either time.
The epidemic abated at the university largely because of the
demobilization of the Student Army Training Corps. At that time it was
still prevalent in Cambridge and Greater Boston.
At Yale University the disease first appeared in the New Haven Hospital
on September 21. There were registered in all departments of the
university 2,265 students. Up to the date of December 24, 1,013 cases
have been treated. The number of deaths from broncho-pneumonia has been
249. At the height of the epidemic, which occurred in the third week of
October, typical fall weather prevailed. An unusually clear, dry October
with very little rain, much sunshine and rather low humidity was the
weather report.
During the period of the epidemic at Princeton that university had 1,050
students, and the first cases appeared shortly after the opening of the
college term on September 24. As a precautionary measure, every case,
when even only suspicious, was sent to the infirmary. In all, there were
about 70 cases in the university and about 45 cases from the United
States School of Military Aeronautics. Only one member in the latter
school died of pneumonia. There were no deaths among the students at the
university. In this part of the country the weather was most delightful
all autumn, being warm and dry, very little rain having occurred since
the end of July. At the date of the inquiry the epidemic had
disappeared—that is, about December 21—there being only two very mild
cases under suspicion. In the town of Princeton, outside of the
university, the conditions were much more serious than in the university
itself. Influenza appeared in the homes of many of the poor people of
the immigrant class, so that it was not uncommon for four or five
members of one family to be infected at once. In one family of seven,
five serious cases of pneumonia developed. An emergency hospital was
opened by the authorities and 40 cases of pneumonia were treated. Of
these approximately one-half died. At the time this report was furnished
the epidemic seemed to have disappeared.
The number of students enrolled at the University of Virginia was 957.
The first cases occurred as early as September 24. There were 290 of
these in number, and three died of broncho-pneumonia. The epidemic was
reported as having abated on December 15, but a few cases appeared after
that date.
_1918 Epidemic at Pittsburgh_
At the Army General Hospital No. 24, located at Hoboken, a few miles
outside of the city of Pittsburgh, on September 28 two soldiers were
taken ill and, with the disease unrecognized, they were removed to the
cantonment hospital at Point Breeze, within the city proper. The men
were found a few days later to be suffering from influenza, and from
this presumable source an epidemic spread rapidly among the troops and
student soldiers located here.
From September 28 until November 20, 1,392 cases of influenza occurred
among the enlisted men. How the infection reached the first two cases at
Hoboken is not known. The command here consisted of the Student Army
Training Corps of the University of Pittsburgh, and Carnegie Institute
of Technology, Motor Mechanics of the University of Pittsburgh and the
Ordnance and Quartermasters’ Department on detached service. The
strength of this command was approximately 7,000. The first case
appeared on September 30 and the diagnosis was made on the following
day. Beginning October 13, all soldiers of this group were inoculated
with two 1 cc. doses of vaccine, obtained from the New York State Board
of Health. At the height of the epidemic there were about 840 soldier
patients in the several hospitals of the city at one time. Cubicles were
used in the hospitals, and in the barracks a floor space of 50 square
feet was allowed to each man. The men slept alternately head to foot,
with paper screens intervening, which were changed daily. In company
formation they were instructed to gargle their throats and clean their
teeth morning and night under the supervision of their officers. Strict
military quarantine was maintained throughout the entire camp, no
congregating was allowed, classes were suspended and only open-air
drills were permitted. For the entire command there were 220 cases of
pneumonia, with 99 deaths, an average mortality of 44 per cent. The
dishes were boiled in the hospitals, and sanitary dishwashers were used
in all mess halls. The kitchen help and personnel were inoculated with
influenza vaccine, with apparently good results. The Magee Hospital,
with 375 beds, was under strict military control. When this was full,
all others were treated in the civilian hospitals.
In the city of Pittsburgh the disease was not made reportable until
October 5. However, one case was reported on October 1, and it was known
that there were a few isolated cases in Pittsburgh previous to that
date. During the months of October, November and up to December 21 there
were 23,268 cases of influenza reported, and the deaths were 1,374 from
lobar pneumonia and 678 from broncho-pneumonia. We cannot but feel that
most of the deaths reported during the period of the epidemic as lobar
pneumonia were broncho-pneumonia associated with influenza. It was well
known among civilians that true lobar pneumonia was exceedingly rare and
has remained so up to the present time. This is especially noticeable,
as this is the time of the year when lobar pneumonia is usually
widespread in Western Pennsylvania. This district was particularly
favored with a mild fall and winter. On October 1 the first case was
reported, on October 15 the epidemic reached its peak—on that day 957
persons being reported ill with the disease. From October 16 until
October 28 it maintained an average of 600 cases daily; from October 29
until October 31 there was a sharp decline from 600 cases daily down to
200 cases daily. From November 1 until December 21 the decline has been
uniform, and on this latter date 58 cases of influenza and 7 of
pneumonia were reported. The height of the epidemic was reached between
October 15 and October 29. During the period of the epidemic in
Pittsburgh, from October 1 until December 15, 62 days were recorded as
cloudy, or partially cloudy, and only 14 days as clear, although the
cloudy days seemed distributed and not in decided groups. The mean
temperature for October was 58 degrees, with normal 54.9; for November,
44 degrees, normal 42.9; for December, 41 degrees, normal 34.7. The
precipitation in October was 3.08, as against a normal of 2.36; in
November, 1.79, with normal 2.55; and in December, 3.50, normal 2.73.
From a study of these weather reports we see that the epidemic occurred
during a period of abnormally warm, cloudy and slightly more moist
autumnal season than usual, but these variations were relatively slight
and far from decided. The confusion of diagnosis between lobar pneumonia
and broncho-pneumonia, associated with or following influenza, occurred
in the Pittsburgh health reports as well as in other cities. The
presumption that almost all, if not all, of the cases reported as
pneumonia of different types were really cases of influenzal pneumonia,
seems justified.
_Epidemic Incidents in Institutions and Towns of Western Pennsylvania_
During the time the epidemic was at its height in Pittsburgh the Western
Pennsylvania Institution for the Blind was in session. This school is
located in the heart of the educational center and was surrounded by the
barracks of the Student Army Training Corps of the University of
Pittsburgh and the Carnegie Institute of Technology. When the influenza
was recognized as epidemic in this neighborhood, the attending physician
at this institution advised a quarantine against the public. The
children were refused visitors in the buildings, and the usual week-end
trips home were forbidden. This school was continuously in session from
September 24 until November 30. During this time there was not a single
case of influenza in the school and the children were free from any
infectious disease. On December 1 the pupils returned to school after
the Thanksgiving holiday, and one week later, on December 8, the first
case of influenza appeared. In a period of five days following 15 cases
developed. It was considered wise to close the school, and all well
children were sent to their homes. The institution was kept closed until
January 1, since which time no cases have developed. Very few of these
children had influenza at home, and only one death occurred.
A reliable report, subsequently confirmed by the health officer, stated
that in Masontown, Pa., the start and course of the epidemic were very
striking. A dance was held in the town and the musicians were brought
from nearby cities. One of the musicians employed was not very well upon
his arrival, and became so ill that after the dance he was put to bed in
the hotel. He was found to be suffering from influenza when examined the
following day, and from him as the primary case the town was swept by
the epidemic.
In Mercer, Pa., the physician to the Board of Health reported that
during September they had a general epidemic of coryza and sneezing,
with slight fever, which lasted for three or four days. This was looked
upon by the people as hay fever. In the midst of this, or about
September 16, a man, 74 years of age, who had been away from home,
developed true influenza, followed by pneumonia, from which he recovered
about October 10. Another man, employed in Greenville, a nearby town,
where influenza was already prevalent, returned to his family here
suffering from the disease. The whole family and all who were exposed to
this family were infected. From this family as a focus the disease
spread rapidly in every direction. There were about 350 cases in the
town of 2,000 inhabitants, and there were 9 deaths. Sporadic cases have
occurred since, ranging in number from one to a dozen at a time. These
numbers do not include scores of cases called colds by the people, but
it seems that all these cases had an influenza element.
In the town of New Castle it was not possible to trace the onset of the
influenza epidemic to a definite case. As the health officer stated,
several cases were reported at once.
The first case of influenza in Indiana, Pa., of which there was any
definite knowledge occurred on September 15. A clothing merchant who had
just arrived from New York, where he had been buying stock for his
store, was the first case identified. The next case occurred several
weeks later, the disease being contracted at the mining town of Coal
Run, in Indiana County.
A man resident in Sharpsburg who had suffered from influenza visited
friends in Fraser Township, Allegheny County, to convalesce. Previous to
his coming that section had been free from the disease. He was still
coughing at the time, and, moreover, he is said to have been a great
talker and visited largely among the neighbors of his host. Threshings
in that part of the township were going on and these he also attended.
The date of his coming was October 13. By October 15 his hostess was
taken ill. By October 16 some of the threshers were affected, and by
October 17 enough were sick to break up the work of threshing.
Eventually all the men engaged became ill, and 11 families were infected
from this source.
_Summary_
Reviewing the history of former epidemics and pandemics, I have gained
the impression, as have many others, that we are not dealing with any
new disease. Further, our knowledge of this pandemic with its high
incidence of broncho-pneumonia shows that it is in no way markedly
different from that of former manifestations of influenza. One is
impressed by the fact that in different outbreaks of this disease of
complex symptomatology certain symptoms or complications have been
prominent, overshadowing others, and making such complications the
striking feature at the time. The failure to recognize that these
varying features are merely different manifestations of one disease has
resulted in much confusion. The observation made in the last
epidemic—and one which can be endorsed during the present plague—is that
influenza has been and is the most widespread, rapid and extensive of
all diseases. One thing also that attracts attention at the present time
is the long period existing between the several pandemics. Whether, as
one observer during the present pandemic has stated, it requires a long
period for the infection to become active and easily carried, or whether
any possible reason can be suggested for these phenomena, admits of no
satisfactory explanation. The outstanding feature during this epidemic
is the complication of broncho-pneumonia, and yet, from very early
times, this complication has been repeatedly spoken of as a striking
characteristic. Reviewing the health reports from the large cities of
deaths from pneumonia, the presumptive opinion seems justified that
almost all, if not all, pneumonias reported as associated with influenza
were of the broncho-pneumonia type. The infrequent presence, indeed the
rare finding, of lobar pneumonia during this period in Pittsburgh seems
to verify the aforesaid opinion. The great frequency and the high
mortality of broncho-pneumonia were particularly noted during the
present epidemic. During the present epidemic the great mortality among
pregnant women was another striking feature, and yet this is by no means
new, having been recorded by some of the earliest writers. Such also may
be said of the recurrence of the disease in the same patient. One
important observation brought out in the study of the pandemic of 1889
to 1892 was that the ordinary infections occurring in the spring and
fall known as grippe or La Grippe are in no way connected with the
pandemics which have occurred. There seems to be a consensus of opinions
among the records of the more recent epidemics, as well as during the
present pandemic, that weather conditions in no way influence the spread
of the disease. Furthermore, a study of weather conditions throughout
the United States, and particularly those of our own city, seem to bear
out the truth of this observation. While clinicians during other
epidemics expressed their belief in the incident of a primary case
producing infection, it has only been during the present one that such
an opinion has not been assailed. The large number of military training
camps and cantonments have undoubtedly offered splendid opportunity for
the spread of influenza. The futility of attempting to control it even
under normal conditions is still questionable. Consistent with former
reported invasions of the disease, the present epidemic lasted a
definite period. This period was about six weeks in most of our large
cities, colleges and institutions, extending approximately from October
1 to November 15.
It is imperative to note the accurate clinical observations recorded
from the numerous epidemics of the past by men with far less data to go
upon than is available at the present day. The high morbidity among the
personnel of many of our hospitals and institutions where the infection
occurred and the relatively low mortality deserve attention. This may be
partly explained by the methods of treatment of those infected, but not
entirely. The great likelihood of carriers of influenza, who either are
not ill or who are suffering from very mild infection, is an observation
also noted by former writers which cannot be ignored. The value of the
masks has not been established, although they have been extensively used
in many parts of the country. Frequent throat lavage was generally
accepted as a rational preventive measure. Relightings of the disease
have been noted in most of our cities after the subsidence of the
epidemic. Vaccination against influenza is fully discussed in Dr.
Haythorn’s paper in this series.
The presence of influenza in San Quentin prison, California, in April,
1918 (Public Health Reports, May 9, 1919); an epidemic of respiratory
disease in Chicago in the spring of 1918; the report of Soper of
influenza in our army camps in March and April, 1918; the occurrence of
influenza in Porto Rico in June; influenza on a United States Army
transport from San Francisco, as reported by Coutant, seem to point to
the possibility that influenza had a footing in America long before the
disease became pandemic. The view held by some that the beginning of
influenza was in America, subsequently being transferred to Europe and
then reimported here, is worthy of consideration. Coutant believed the
disease originated in Manila, others that it traveled from “a permanent
endemic focus in Turkestan,” and there are many other theories which
attempt to discover the original source of the disease. The question is
today an unsettled one. The pandemic of influenza in its severest form
swept so suddenly over the world that before the profession realized it
or had become stabilized it had changed its character and the great
plague was gone. The consequence has been that we have really learned
little that is new and have done scarcely more than establish on a firm
basis many of the opinions formed after the great outbreak of some 30
years ago. Because transportation is today more rapid than it was at
that time, so the spread of the disease has been correspondingly swift.
Our modern life, the congregating crowds in theatres, moving-picture
houses and in lecture halls, as well as of the men in our training
camps, the development of street cars and the more frequent traveling by
train—these and many more changes in our mode of living have served to
aggravate the conditions favoring the widespread distribution of the
infecting agent. A higher proportion of the population was, therefore,
attacked than in any previous pandemic, and the period during which the
disease was widely prevalent has for the same reason been relatively
much shorter.
The characters differed somewhat in different regions, but the evidence
shows clearly that we are not dealing with any new disease. It will be
years before we are able to fully analyze the data that have been
collected from such wide sources and by so large a body of trained men,
so that important epidemiological facts may still be forthcoming from
the material already at hand. We are too close to the events to get the
most helpful perspective, and the object of this report has been to add,
in however small a degree, to the general knowledge of this great
pandemic as it has appeared to us in Pittsburgh and its surroundings.
A CLINICAL DESCRIPTION OF INFLUENZA AS IT APPEARED IN THE EPIDEMIC OF
1918–1919
By J. A. LICHTY, M. D.
The epidemics of influenza which have been recorded from time to time
during the past few centuries have always contributed an interesting
chapter to the history of medicine. The protean character of the disease
with its many complications is always an excuse for another attempt at
the description of the clinical manifestations of a recent epidemic.
This is not, however, the only incentive at the present time for
describing the clinical aspect of the disease as it appeared in the
epidemic through which we have just passed. The study of the disease
from other aspects, such as the pathological, the bacteriological and
the physiological, by well-organized groups of workers has made it
necessary to co-ordinate, if possible, the clinical findings in every
detail with these apparently basic principles. It would be interesting
to review here the peculiarly fortunate circumstances which have led to
the investigations. On account of the great war many temporary
laboratory organizations which otherwise would not have existed were in
operation, and these organizations, moreover, were keen to undertake any
laboratory problem which might arise. The present epidemic presented the
opportunity, and that the work was taken up with great enthusiasm is
evidenced by the reports coming from the various army hospitals, base
hospitals and civilian hospitals throughout the world. The permanent
laboratories connected with medical schools and with institutions for
medical research took up the problems with equal endeavor. This brief
reference is made only to call attention to the fact that from such
organizations a great mass of information has come which must be
critically reviewed and coordinated before it can add to the permanent
fund of our knowledge of the disease under consideration.
The material upon which the following clinical observations have been
made is peculiarly adapted to review because it consists of two distinct
groups of patients which were admitted to the Mercy Hospital. One group
of 153 men was composed of soldiers between the ages of 18 and 23, which
had been recently inducted into the Student Army Training Corps, and
were living in barracks in the immediate vicinity of the hospital.
Another group consisted of civilians (394), ranging from youth to old
age, which came from various parts of the city and surrounding towns and
country. The first group came to the hospital early, or as soon as the
disease was recognized; the second group came usually after several days
of illness had elapsed, or when a complication had already arisen. Many
of this group had been ambulatory cases for the first part of the
disease. The entire number of patients admitted to the Mercy Hospital
from the first admission, September 21 to December 1, the end of the
quarantine, was 547. After December 1 very few simple influenza cases
were admitted. These 547 cases form the basis of the observations which
will be referred to in this paper.
From the last great epidemic or pandemic of influenza, that of 1889 and
1890, have come clinical descriptions which should be reviewed before
speaking of the clinical manifestations which have characterized the
present epidemic as shown in the two groups studied.
One of the best descriptions of that epidemic was given by Dr. O.
Leichtenstern in Nothnagel’s Encyclopedia of Practical Medicine. This
contribution, among many others, describing the epidemic of 1889 and
1890 is one of the first to refer to the Pfeiffer bacillus as being
etiologically associated with the disease. It differs, therefore,
greatly from descriptions of previous epidemics. Leichtenstern says:
“The typical influenza consists of a sudden pyrexia of from one to
several days duration, commencing with a rigor, and accompanied by
severe headache, generally frontal, with the pains in the back and
limbs, by prostration quite out of proportion to other symptoms and
marked loss of appetite.” He continues by saying that to these
characteristic symptoms may be added the catarrhal phenomena arising
from the affection of the respiratory tract, particularly the upper
(coryza) and “occasionally” the lower, the trachea and bronchi. This
description is so in accord with the symptoms of uncomplicated influenza
as found in the present epidemic that very little need be added. Any
difference which may occur in the description of the disease is likely
to be accounted for by the peculiarity of onset, whether in the upper or
lower respiratory tract, and by the different ways of interpreting
complications which may have arisen. It is evident from this description
that the upper respiratory tract was affected more generally than the
lower in the epidemic of 1889 and 1890. In the present epidemic it can
safely be said that the reverse was the usual state of affairs. It was a
rather unusual occurrence when the affection was limited only to the
nose, pharynx, larynx, trachea and larger bronchi. A very large number,
no doubt, had a peculiar œdema, a so-called “wet lung,” which we shall
discuss later; others went on to a capillary bronchitis or a
bronchiolitis, and a large number had broncho-pneumonia. This sequence
we shall attempt to show in the statistics at hand. In some cases the
lesion in the lower respiratory tract seemed to be primary, there having
been no initial coryza. At least none was observed and no history was
obtained.
_Prodromal Stage and Communicability_
The length of the prodromal stage—the stage from the time of contact to
the earliest onset of symptoms—has always led to interesting
observations and discussion. In this epidemic we have rather definite
information bearing upon this subject.