Part 3

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.