Part 16

Case seven had been ill seven days before admission with cough and fever. On admission his temperature was 105°, pulse 116, respiration 24. Case eight gave a history of having had a cough for eight days previous to admission. This cough had not incapacitated him much at first, but he became progressively worse during the four days before admission, with increasing shortness of breath and abundant yellow sputum which he found it difficult to raise. On admission dyspnoea with cyanosis was very evident.

Even from these detailed clinical descriptions it is impossible to say definitely whether the disease was or was not influenza. There is no doubt, however, but that clinically the disease resembled more the so-called streptococcus pneumonias that were observed in the United States camps in the winter of 1917–18. The descriptions of the mode of onset are particularly at variance with the onset as we know it in influenza.

Those who believe that the influenza bacillus is the cause of influenza maintain that the finding of this organism in a large per cent. of cases by both groups of observers is valuable evidence. For reasons previously stated we cannot agree.

Description of the epidemic features is not detailed enough to be of assistance. The first group of authors remark that the disease constituted “almost a small epidemic.” The second group say that six out of eight cases in their series of candidly reported patients came from one command. The former report on twenty cases, the latter on eight. The latter remark that although they have dealt with only eight cases in detail, they had a much larger number altogether. Presumably there were a decidedly larger number of patients in both hospitals, but the actual number is not stated. In short, we do not know whether the disease appeared to be more or less epidemic than the apparently similar disease among our troops in the winter of 1917–18.

Both groups of observers have described in some detail the pathology of the cases which were necropsied. The author in attempting to obtain further comparative information has submitted the pathologic descriptions given by the British authors to Dr. E. W. Goodpasture, who has very kindly pointed out the points of similarity and difference between the gross and microscopic findings in these cases of purulent bronchitis, and the same findings in typical influenza. He says that the lung picture, as described, is not the same as that which was typical of the acute influenza observed in the autumn of 1918 and again in the winter of 1920. The characteristic picture in the latter is primarily an extensive involvement of the alveolar structure, while as Abrahams and his associates remarked, the condition in their case is primarily “an affection of the bronchi and bronchioles, and not of the alveoli, though the alveoli may be affected later, if the patient survives long enough.” Goodpasture states that the pathology as described by the British authors is very similar to the lung picture in interstitial bronchopneumonia described by MacCallum for the post-measles and primary bronchopneumonia among our troops in the winter of 1917–18. The streptococcus and the influenza bacillus were dominant organisms in MacCallum’s series. It also resembles the pathologic picture described by Pfeiffer in his original article on one of the late recurrences of the 1889–93 epidemics of influenza.

In summing up, we must admit that it is impossible to reach a definite conclusion, but that both clinically and pathologically the disease described among the British troops in 1916 and 1917 was not typical of influenza as we have known it more recently. The similar conclusion reached by Carnwath, presumably chiefly from epidemiologic considerations, has already been described. We do not deny that this “purulent bronchitis” _may_ have been influenza. On the contrary, it is a part of our hypothesis that influenza under the proper conditions may become epidemic in practically any land. But we do believe that the evidence has not shown that the disease among the British troops in 1916 and 1917 was an etiologic precursor of the great pandemic.

To return to a discussion of influenza in China, we quote from an article by Cadbury in the China Medical Journal: “Unfortunately no health reports are available for the greater part of the Chinese Republic. We have consulted, however, the Health Reports of the Shanghai Municipal Council from 1898 to 1917, and among the total foreign deaths we find that only the following were attributed to influenza: 1899, one death; 1900, one death; 1907, four deaths; 1910, one death. After this no deaths are recorded from this cause up to and including the year 1917.

“In the Hongkong Medical and Sanitary Reports, which give the total deaths registered in the Colony, we have examined the records from 1909 to 1917. During these nine years only two deaths were attributed to influenza, and both occurred in 1909.

“From a personal letter from Dr. Arthur Stanley, Health Officer in Shanghai, dated February 11, 1919, I quote the following:

“‘As to influenza we had an attack beginning at the end of May and lasting through June and again in the latter part of October and lasting through November. The latter was somewhat more severe. The noteworthy features were general absence of catarrhal symptoms, congestive pharynx frequent, as also was a slight erythematous blush on the neck and chest, which made one think at first of scarlet fever. Fatal pneumonia common among the Chinese and Japanese, but among Europeans very little pneumonia.’

“In his report for May, 1918, Dr. Stanley says that the disease was reported to have reached Peking before it came to Shanghai, but subsequent reports showed that most of the river ports were almost simultaneously infected, the rate of spread conforming to the rate of conveyance by railways and boats of infected persons. The mortality was very low.

“Newspaper reports indicate that a third appearance of the disease in Shanghai occurred from the middle of February, 1919, which was still prevalent in April. The symptoms were much more severe.

“For Hongkong I quote from a personal letter from Dr. Hickling, the Principal Medical Officer of Health, dated January 29, 1919:

“‘The epidemic of influenza in the spring was a very mild one, so far as we can judge. The disease did not last more than a few days in most cases. The recent epidemic (October, November, December and January) has been much more severe, often lasting two or three weeks.’

“Only one death, which occurred on May 14th, was reported from Hongkong in the spring. In the later epidemic the deaths reported were as follows: October, 70; November, 95; December, 67. The first of these deaths occurred on October 5th. The figures for January had not been compiled, but the disease was diminishing.

“Dr. C. W. McKenny of Hongkong has kindly furnished me with the following facts: ‘During the first five months of 1918 there were twenty-two admissions for influenza to the Civil and Tung Wa hospitals (3 in May). In June there were 269 cases with three deaths. In July, August and September, 43 cases; and during October-November, 130 cases with four deaths....

“‘The June epidemic in Canton appeared first at the Pui Ying School, then among the employees of the Post Office, the staff of the Canton Hospital, the Canton Christian College, and the Kung Yee Hospital. The other schools entirely escaped. Eleven days were taken by the disease to spread from one part of the city to the various other parts.’”

Plague appeared in the north of China in 1917, originating apparently in inner Mongolia. The spread extended over quite an area, and it is reported that this epidemic of pneumonic plague has been more extensive than any since that of 1910–11. The disease was first reported prevalent in Patsebolong December 6, 1917. The diagnosis was confirmed bacteriologically, and there can be little doubt but that the cases of plague reported in various parts of China even up to March 18th were true plague, and not unrecognized influenza.

SECTION III.

In the following section of our report we shall have frequent occasion to refer to a series of investigations conducted by the author in the City of Boston during the 1920 influenza epidemic. We will explain in some detail at this point the nature of the work done and the methods used, in order that the subsequent references will be readily intelligible.

AN INVESTIGATION OF INFLUENZA IN BOSTON DURING THE WINTER OF 1920.

Following every widespread epidemic interest centers in the question as to how much havoc the disease has wrought, what proportion of the population fell victim, and how many of these died. With regard to influenza the vital statistics of all countries are decidedly insufficient in furnishing this information.

In nearly all countries influenza is not a reportable disease. Usually, as was the case in the United States in 1918, the disease was made reportable during the epidemic, but this took effect usually at least two weeks after the epidemic had started in a community. Further, there is probably not a single community in which the reported cases of influenza reach to anywhere near the total of actual cases. The question of diagnosis, which is not always easy even in the presence of a pandemic, causes some physicians to hesitate to report cases. Other physicians “play safe” and report nearly everything as influenza. Finally, in the period of an epidemic, the physicians are so pressed with caring for the sick that they very naturally neglect to report cases as they occur.

It becomes necessary, therefore, in collecting evidence in civil populations, of the morbidity and fatality from influenza, to obtain additional information to that available to the Health Officer.

The method which may be relied upon to give the most accurate data consists in house-to-house surveys made soon after an epidemic, in which competent inspectors obtain detailed information concerning the illness or freedom from illness of every individual in the areas canvassed. The majority of individuals interviewed will not have had the disease, and it is therefore essential that in such a census a large enough population be covered that the resulting figures will be truly representative of the population at large.

Toward the end of January, 1920, when the recurrent epidemic was at its height in Boston, the author undertook with the aid of thirteen trained social service workers, and one physician, who was a graduate of the Harvard School of Public Health, to make a sickness census of 10,000 individuals. Six districts were chosen in different sections of the city, representing six different economic and social groups. Great care was exercised in selecting the districts, so that the population in each might be as homogeneous as possible regarding economic and sanitary status, as well as race, and living conditions in general.

We have sought to clarify and to abbreviate our description of the characteristics of the various districts by incorporating a map, together with photographs of typical streets in each district. One who compares these streets as they are seen in the photographs would scarcely find it necessary to enter the buildings in order to discover the living conditions of the occupants (Chart XIII).

CHART XIII.

District I includes an Italian population of 2,000 individuals, one-half of which live in the most congested portion of the city (see photograph) known as the North End, while the other half, living in East Boston, are slightly less crowded.

District II, in South Boston, consists of 2,000 individuals almost entirely of Irish race stock.

District III, like District I, consists of three groups living in very similar environment to the two groups of the first district, but composed chiefly of Jewish race stock of various nationalities. The photograph for this district represents the area in the “West Side” near the Charles River Basin. The area in the “South End” is of similar type, while the area in East Boston is housed similarly to the Italian district in East Boston. The dwellings in both of these latter districts correspond to those shown in the second photograph of District II.

While the first three districts comprise tenement areas, some poor and the remainder very poor, Districts IV and V represent the middle class, and consist nearly entirely of “Duplex” and “Three-Decker” buildings. The first of these comprises 1,000 individuals of mixed race and nationality, the type broadly spoken of as American. The second consists of a Jewish population of 1,600.

In District VI are included 1,400 individuals belonging to the well-to-do and moderately wealthy families of Brookline.

The six districts may be considered as representative of the various strata of society, so that we are enabled to study the influenza and its mode of action under varying environment. We have selected areas in the city consisting of households or homes rather than boarding houses and rooming populations. After a few attempts in the latter group we became convinced that the information obtained in rooming houses was utterly valueless. In the Jewish districts we were able, through the kind co-operation of the Federated Jewish Charities, to use trained Jewish Social Service Workers, each of whom had previously worked in the district assigned to her, thereby possessing the confidence of the inhabitants. They were also able to speak the language. One-half of the Italian district was surveyed by an Italian physician and the other half by an American Social Service Worker who knew the Italian language.

The information obtained was recorded on printed forms, which were filled out in accordance with detailed written instructions. Form “A” contained the necessary information concerning the family as a whole, including statistical data of each individual, description of the dwelling, of the sanitary condition, of the economic status, etc. Form “B” was filled out for each individual and gave detailed information as to the occupation and illnesses during the 1918–19 or the 1920 influenza epidemics, or during the interval. Form “B” was so arranged that the inspector was not called upon to make the diagnosis of influenza, but to record the various symptoms as described by the patient. The decision as to the diagnosis was made later, by the author. All blank spaces were filled in with either a positive or negative answer, so that the reviewer knew that all questions had been asked and answered. (See Appendix.)

The inspection was begun on February 9th, at the height of the epidemic. All records were turned in and reviewed by the author, who blue-penciled obvious inaccuracies and incorporated directions and questions in those instances where he desired further information. The records were then returned to the inspectors who, at the termination of the epidemic early in March, surveyed the entire 10,000 a second time, checking up their first record, correcting any inaccuracies, and adding records of additional cases of influenza which had occurred in the interval.

The most careful statistical surveys and compilations are not without error. We have gone into considerable detail in the preceding description in order to demonstrate the several checks that have been made upon the work, without which information others would be unable to judge of the accuracy or value of our work.

_Diagnostic standards for the 1918 epidemic._—All cases of illness recorded on the reports, which have occurred during either the 1918 or the 1920 epidemics, or in the interval between them, have been put into four groups as regards diagnosis of influenza. Cases are designated as “Yes,” “Probable,” “Doubtful,” and “No.”

Cases of illness occurring during the months of 1918 and 1919 in which influenza was epidemic and in which the patient remembers that he had the more definite symptoms, (fever, headache, backache, pain in the extremities, pneumonia) and in which he was sick at least three days and in bed at least one day, have been designated as “Yes.” The symptoms chosen are those most likely to be remembered. The individual frequently does not remember all. Statements of the absence of fever are often unreliable. Usually the headache, backache or pain in the extremities, or even all of these are well recollected.

Cases occurring particularly during the epidemic period in which the more definite symptoms are unknown, but who were sick three days or longer and who were in bed at least one day, were probably influenza. This is particularly true if there were no other symptoms suggestive of some other definite disease. Such cases were designated “Probable.”

Cases have been designated as doubtful when the evidence of illness falls short of the above desiderata. Cases of true influenza may fall into this group, either because of the extreme mildness of the symptoms and course or because of the inaccurate memory of the individual concerning the events of his illness sixteen months previously. Our results show that the group of doubtful cases is relatively very small and the number of true cases lost in this group will be negligible.

One important reason for adhering to the above classification is that it corresponds closely with that used by Frost and Sydenstricker, so that our results may easily be compared with theirs.

_Standards for 1920._—For 1920 the illnesses were so recent in the minds of the patients that we have required rather full information for making the diagnosis of “Yes.” For this designation certain symptoms are arbitrarily required. Certain additional symptoms, if present, serve to strengthen the diagnosis of influenza. The required symptoms are fever, confinement to bed for one day or more and at least two out of the following three, headache, backache and pain in the extremities. The additional symptoms which influence the classification are sudden onset, prostration, lachrymation, epistaxis, and cough.

Cases designated as probable are those in which the symptoms as enumerated above are incomplete in one or more details, but yet in which the diagnosis of influenza would be justified. “Probable,” therefore, means that the case is to be accepted among the list of true influenza cases. This is particularly so when the case occurs during the epidemic period.

“Doubtful” applies to those cases in which the evidence although suggestive of influenza, is not complete enough to warrant such a diagnosis. The doubtful feature may be in the lack of too great a number of the symptoms enumerated, or the presence of symptoms which might be due to some other disease. Certain cases occurring at the same time with other cases of typical influenza in the same household, and which would otherwise have been recorded as doubtful, have been marked either “Probable” or “Yes.”

_Standards of severity._—A purely arbitrary classification of severity has been adopted. Probably no two observers would agree exactly on a classification of this nature, but for the purposes of this study the following will suit all requirements provided the standard used is carried in mind throughout the comparison.

If a patient with influenza is under medical care, and the case is one of ordinary severity, the usual period in which the individual is advised to remain in bed is one week. This is the basis of the criteria of severity.

_Mild._—A case is recorded as mild if the individual has remained in bed three days or less; _Average_, if in bed four to seven days; _Severe_, if in bed over seven days. _Pneumonia._ This designation is added to that of “severe” only in case the physician made such a diagnosis, or if the evidence under “symptomatology” leaves no doubt as to the condition.

Examples of individual exceptions to the preceding general classification are as follows: An individual in bed two days, but sick for three weeks might be recorded as average. A mother, with a family of sick children and who spent no time in bed may have been a severe case of influenza. In fact, we have allowed ourselves a certain latitude in individual cases in classifying both the diagnosis and the severity of the disease.

In the final tabulation we have included both the “Yes” and the “Probable” as being cases of influenza. This has been done after a careful comparison of both groups.

As a check upon the reliability of the work we have compared our results for the 1918 epidemic with those reported by Frost and Sydenstricker and have discovered that with regard to the general subject discussed in both studies there is close agreement. This is important in view of the long period that has elapsed between the first pandemic and the time of our survey, and because we are unable to compare our tables of incidence for 1918 with those for the city or the state at large. Our own records do not place the date of occurrence of the disease in 1918 any more closely than by month.

We have compared our 1920 incidence curves with those of Massachusetts and find a close correspondence, particularly in the date of onset, peak, and disappearance of the epidemic. We have done likewise for the occurrence of the disease in the city of Boston at large (Chart XIV).

In the past but few house-to-house canvasses have been made with relation to influenza. Auerbach, following the 1889 epidemic, collected statistics on 200 families distributed throughout the city of Cologne. Abbott, while not conducting a canvass, did obtain a certain amount of valuable information by letters addressed to physicians, institutions and corporations throughout the State of Massachusetts.

There is fairly abundant literature on the disease as it occurred in institutions. Moody and Capps, in a study of the epidemic in Chicago in December, 1915 and January, 1916, made a survey of the personnel and inmates of four institutions in that city. Among other rather numerous statistical compilations from institutions we may mention that of Hamilton and Leonard which was devoted particularly to a study of immunity, and that of Stanley at San Quentin Prison, California.

Garvie has reported his personal experience with influenza in an industrial area and discusses the disease as it has occurred in families in his private practice.

Carnwath reports a “block census” undertaken by Dr. Niven in Manchester, England. This is of the same nature as our own work. Reeks has made a detailed house survey of 2,757 persons in New Britain, Connecticut. D. W. Baker has conducted somewhat similar surveys for the New York Department of Health, and Winslow and Rogers quote the excellent record of the Visiting Nurse Association of New Haven, in which they have information for all of the families cared for by the nurses. This, however, is a collected group and does not correspond with the so-called block census.

CHART XIV.