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1959 Influenza: past and present Jack Frederic Bowers Yale University
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INFLUENZA: PAST AND PRESENT
By
JACK FREDERIC BOWERS Lafayette College, A.B. 1955
A thesis presented to the
Faculty of the Yale University School of Medicine
in candidacy for the degree of
Doctor of Medicine
Department of the History of Medicine T i \3 V \ 2~. TABLE OF CONTENTS
Chapter I: Historical Page 2
Chapter II: The 1918 Epidemic Page 6
Chapter III: The 1918 Epidemic in Easton, Pennsylvania Page 9
Chapter IV: Influenza Investigation Pa ge 17
Chapter V: Influenza 1957 Page 21
Chapter VI: Conclusion Page 26
Bibliography Page 27 Digitized by the Internet Archive in 2017 with funding from The National Endowment for the Humanities and the Arcadia Fund
https://archive.org/details/influenzapastpreOObowe 2.
Chapter I
Historical
Mention has been made of what we now term influenza epidemics by- most every ancient writer sometime during the course of his literary career. Hippocrates and Livy both wrote of the curious, sweeping illness of 112 B.C..1 Diodarus Siculus described an influenza-like epidemic which swept through the Athenian army in Sicily in 415 B.C.. Warren Vaughan, in his monograph on influenza, felt that the pestilence which took the lives of thousands of Greek soldiers during the seige of Syracuse was in retro¬ spect influenza. He goes on to mention reports in 876 A.D. of a cough which
O swept through Italy taking the lives of many of Chorlemagne*s troops." Dr.
August Hirsch, German physician and medical historian of the nineteenth century believed the first epidemic that can be definitely said to be in¬ fluenza occurred in 1173* This had been misinterpreted by some to mean that the first influenza epidemic took place in 1173, but a more accurate translation from the German has clarified the issue.
An influenza-like disease designated Furacht or Slaodan was described in an Irish manuscript in the fourteenth century as resembling the devil's prostration, and was mentioned again in the fifteenth century in The Annals of the Four Masters as epidemic throughout Ireland. 1 Gaelic documents at that time used the word creator from crest, meaning chest, to imply in¬ fluenza .
1 Vaughan, Victor C. Epidemiology and public health. St. Louis, Mo., C. V. Mosby Company, 1922, vol. 1, p. 3OO. p Vaughan, Warren T. Influenza. An epidemiologic study. Amer, I. Hyg., 1921, monograph series no. 1, p. 2. 3 , Tnompson, E. Symes. Influenza or epidemic catarrhal fever. London, Percival and Company, 1890^ p. T7 ~ •: ) - ■ - '
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The first accurate and complete description of an influenza epidemic in the English-speaking world came to us in 17^9 from the pen of Dr. Thomas
Short of London.1 Dr. Short endeavored to describe the course of an in¬ fluenza epidemic which struck London in 1510. He postulated that the di¬ sease began in Africa, crossed the Mediterranean Sea in 1509 to Sicily, proceeded through Italy, passed over the Alps into Germany approximately two months later, struck throughout western Europe scarcely missing a family, and finally crossed the Channel into England in the spring of
1510. Dr. Short went on to describe the symptomatology quite accurately, noting headache, difficulty in breathing, hoarseness, anarexia, weakness, a productive cough, and severe prostration of varying degrees in almost every case. He went on to say that the disease in 1510 had a duration of approximately eight days, and claimed only the lives of children. The physicians of the day were unanimous in their therapy using bole ammonias, oily lintus, and pectoral troches. The use of blood-letting, a popular medical treatment of the times, was found to be contraindicated, and when used, promoted serious complications and often death. Dr. Short, after his initial work, went on to describe similar periods of sickness which swept across England in 1557, 15^0, and again in 1610. He ventured in his later works to postulate the positive association of the epidemics with natural phenomena such as earthquakes, volcanic eruptions, and celes¬ tial displays. Short's writings were instrumental in establishing a prece¬ dent in description which later investigators such as Willis, Sydenham, and Huxam followed and elaborated upon.
Willis, in his Practice of physlck, 1685, recognized and recorded
1 Thompson, E. Symes. Op. cit., p. h. < ' [Ini 0 aoti'-r.t'ni-gofc echaiqmoo sine! f- • ;•• ]
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Dr. Willis was greatly interested and concerned in Short's postulation that influenza tore a close relationship to concurrent physical and geological upheavals. In 1658 Willis took issue with Short’s thesis, end stated that he could find no relationship between the occurrence of influenza and physical phenomena, temperature changes, or geological happenings. His records served as an example to other workers in medical observation, and in fifty-five of the years between 1800 and 1875 epidemic influenza was reported by a medical observer somewhere in the world. Abbott, writing about the 1889-90 epidemic, states that in the fourteenth century there were six influenza epidemics, seven in the fifteenth, eleven in the six- 2 teenth, sixteen in the seventeenth, and eighteen in the eighteenth century. From these reports we see that man's investigative mind enabled him to recognize long before he recorded the existence of a curious disease which struck entire populations as it swept from one locale to another. He referred to this specific malady as Gallant’s disease, Pfeiffer's malaise, and catarrhal fever to mention only a few which have remained until today; however, it was the Florentines who first used the word 3 influenza to designate the disease as we now know It.'" The misery of an epidemic and the realization that there were more epidemics to come plagued medical science throughout the nineteenth cen¬ tury, A cause and effect relationship was sought, but continued to evade medical researchers time and time again. In the midst of the 1892 epidemic, Francis, Thomas Jr. Influenza; the newe ecquayntance. Ann, int. med., 1953, 39, 204. 2 Vaughan, Victor C. Op. cit., vol. 1, p. 300. - Wyeth Laboratories. Influenza 1957, 1957, zl. • Ui ■ , 'J j ■ --.IP ,•/ im’-tolia < y-. i ' ' - , , r" ' . -...o- 'J c' ■' ■ ■ : •' >' I ' ••• i , , ’ ■ t oo i tt &onorfftfjoac said1 naswj^tf cl uenoi tslai oa frail Ik ■ ' ' • ' • u t r. n-v » . i ’ o'c . J ‘iow *j©■■<& f . , < OOi ' ‘To fit . . ■ w ... t« . r,tiD»Jbiq® QQ~ ~ l r ■ ' i • r .1 • . i . O* V .y-i. ; ■ ,-xi „ . 1 -V. .t ■ r: . 0 ' 4* ».'>'* ' T ‘»1 ' ■ ' - . "> i ■ " ;i.i • , > »’ : , '..id . ni 'n i J' rfrrr; " , ; ... ' .■ - -v v ■ . •: -. / : t-'' i i ^ 1- r ct. . nc o • icv • i .n i ’ C'--'..: y-1 ■ ■>' r - ■rf ' ' '. " ’ '' i ao-. •»' -1 in’- : • Inc at..' i •/•*'.»! •• *i V fie ,. - -ir '■ .• t? , •, . • w i - w ' ,'i ‘‘ ; •>* ■ aoJ -Itivj l c x: ' r.fl !»w . • • r 1 -J (.r. i c ; ;t4. ri'tir .tno; ;h ala rfet .r:: o.>x<’ ■ ael • i in v x .< «• o o& r.t. «ii<; Oit -IV: tft' O ■ i (0fh« ‘3 '-v : i a-.(iol /-i i ? i ; .1 -cito A . 'ic dffebio ©rffi ni .nt. i - ; ' .4CS . ic ,T• • 1 ,X„ X JJ: J.rinl . t.rti-ro.tsxoqti at»vW 5- S. Pfeiffer isolated the bacillus now called hemophilus influenza, and postulated this to he the cause for the epidemic disease.^ This observa¬ tion gained wide acceptance, and Pfeiffer's bacillus was held responsible for the influenza epidemic of 1899- Medicine now believed it had found the long evasive etiological agent, and cure and control were just around the corner. Much evidence poured in during the next decade to substantiate and support Pfeiffer's findings. The world now felt better prepared than ever before for influenza to strike again. Pfeiffer, his associates, and most epidemiologists of the time waited patiently. Their wait was short, for in January 1918 an outbreak of what seemed characteristic of influenza appeared in northern China. The primary, localized outbreak was recognized, but was not considered widespread enough to be of much consequence. Little did investigators relize that within a year and a half, twentjr million people would die as a direct result of this seemingly insignificant, localized, Chinese outbreak. & Smith, David T., Conant, Norman F. et al. Zinsser bacteriology. New York, Appleton-Century-Crofts, Inc., 1957* P- 732. ,.( :i L • s • r . .3 , , ■ i, - i:‘ '<• - -VL . :: - - '• . , - ■■ L-i. . v , - V > i-* 1 - ' ' • : ! r ’ • 1 • ' ' '; si ] . ;■ ,f. ,j ii-a", r- i a ■ ■ ‘ " y <: ^ ■■■<** ■ '‘-'J r - 'a- . i IL'iTJ *c oj ■ T ,. .. . ; - ■-> : • )- - V • 1 6. Chapter II The 1918 Epidemic The first report of influenza in the United States came from an army post, Camp Funsten, on March 1918. By the end of March a mild form of the disease was Being reported from almost every city east of the Mississippi. There were many current opinions at this time concerning the place of the primary focus of the disease. Clifford Gill Believed that the continental land masses of central Asia and Canada, Because of their favorable climatic conditions, served as endemic homes for potential epidemics and remained reservoirs of infection. He went on to apply his quantum theory to the epidemic which explained the outbreak in terms of a loss of equilibrium Between infection and immunity.’*' Chaufford, Netter, and MacNeal Believed the pandemic had its origin in France, Alberto Lutraria placed the focus in the United States, and McNalty stated his not hitherto mentioned Belief that the pandemic had an origin consisting of multiple foci. While these various views were Being debated, influenza made its first appearance among American troops in Brest, France, in April, 1918. Many thought that this event was the start of the soon present European epidemic, But later reports showed that there were re¬ ports of mild, documented cases in England Before the arrival of the American troops in France. Begardless of the focus or foci, the epidemic reached Scotland, Spain, Greece, and Egypt By May, and engulfed all Europe, China, and India By July 1918. As ships returned American troops to Boston in August, the mild cases aboard ship provided the spark which was respon- Gill, Clifford A. The genesis of epidemics and the natural history of disease . London, Bailliere, Tindall, and Cox, 1926,"p."223• 2 Burnet, F. M. and Clark, Ellen. Influenza. Melbourne, Australia, Macmillan and Co. Ltd., 19^2, p. 70- i • J' ; ' • ' .. • J ii . ■>. . oc i J. .u qm :• • <. _■ ffeo it i .. h . . ’ •> 1o an i.l • >■ ; • • i ; r-0- • ' , 0 J I I ' \ J Lla to : J f .... ;%a . I ’ 1 f ' 0 : " . .P ti>. n< ' U J ‘ • i-J ■.. or . • <. u • ■ w • i r: J' ... . O' ii . ' - ■ . n ' 0-1 ' a t.■■■'..■ tc ri ■ . tl . • > . ,i ‘.iwi i n ii a - . r i ujtiJ ti j ■ > : . j .. , . 1 ■ - 1 .1 J ' J J . li . . v r. • IT' ■; . .' •• . • , ■ r !■. o., o' : . a. ' . ...i- - . .. "O o iJ-: .1 .O'.; ;i ;.l n.’ .r.i-.O .•/ rfyfv io ■ ; / , / i" . io,. . .*iuii To a' . a - .it - o* 7 l‘- " a . • >— i .1'. It .. . .; taeve -*i , • ' o . . -.<• - ■ .. •'< . -k...... n . i j »• v jO . i. li.:: ‘:c .r. -r j .. a. • 1 ■ .. -j1 >''. •vl O : L ..U •- 1 • . i: X "Ki " r ‘ 'Vl .O’, . I '• J'' l • • . OJ :oC' i • *..A . j " ^ . V ■' : ‘i i/.'- ‘ .a -ao. > f l / - .11J j £'tO‘,( r til~ .~ct "! 1 i • 1 . O 1 ■ : , •< > u' . in .iod M • il .n-o ... - . . . ,itnt sE 7. sible for the 1918 epidemic as we now remember it. By October 5th, 1,211 people had died in Boston, and the whole Atlantic seaboard now experienced an epidemic which was going to prove fatal to 39O out of every 100,000 1 people in the United States. Within six weeks the entire country had been attacked. With the exception of San Francisco, the eastern seaboard cities reported the highest mortality rates. Philadelphia experienced the 2 highest rate in the country, .losing .77 per cent of its population. Victor C, Vaughn, at this time, classically defined influenza clinically as an acute febrile disease of extreme communicability, characterized by catarrh of the respiratory tract accompanied by pains in the head and ■3 musculature.' The period of incubation usually was from two to four days, with a sudden onset and marked prostration. The duration varied from, a few days to several weeks depending upon the severity of the attack. The explosive outbreak in the fall of 1918 was characterized by many unexpected occurrences, public health reports in 1920 state that . ii the incidence was highest among the 5 to 9 and 23 to 34 year-old groups. Incidence was 6 per cent higher in the male population, and. whites were more commonly infected than negroes. It was also shown that the attack rate increased as the number of rooms per house decreased. Mortality 1 Burnet, F. M. and Clark, Ellen. Op. cit., p. 70. 2 Vaughan, Victor C. and Palmer, George T. Communicable disease in the United States Army during the summer and autumn of 1918. J. Lab. Clin. Med., 1919, -k, 59I. 3 Vaughan, Victor C. On. cit., vol. 1, p. 297. 1 Frost, W. H. Influenza - prevalence in the United States. Pub. Elth. Rep. (Wash.), 1920, 35, 579-598. _ ■ ■ ' !-• : :o ■ i' io : i: f J : . ,.C ' ' ' ' ' ; ;• (;■- o. i ■ 1 .;••• i; r- ? j ■) * : :» 1 . ':i’ • :v: r n fi r< i. 1 t ' ' '' , ' ( :i ■ . .< : -u . . ,i - n ’> ('.J '/ . v; . L i , >•' ;j :.cm2‘: i • •• i 0 ,* 1 . I ' ‘ .n ■ /> . *£OJ' 2.7 Jiv' t! ?■ >■’ .1 [ . • . - ■ • , • / ;• ; : • • ; • ■ > j ■ . I -..'if . j’ /; i ,.j '• .< ‘ (1 > V O «’ ' ' i i' • • r . . - < v- ■ i i- ‘ • .1 .1 .» ;■ , ; iv m1 • ! .'*■> .1. . 1:*C O ' fi ' ; r • n. .jj • , • - * • J:V .1 >1.2 . ■ ' • , . J- j .r? . ) . r . . 1 . \ . vl> r • (W -n , n- . -Ti-Mf- ;t t.> . r. - i-*1 ' .C ,1 • . ' -.O i I ' ,«• i j• V i 8. statistics showed that the highest death rates were found among both males and females under five years of age, males between twenty and forty years, and both males and females over sixty. By the fall of 1918 nearly four million men were interned in the United States military service. During the four autumn months of 1918, 33®? 3^3 cases of influenza were reported to the Surgeon General.^ This constituted one out of every four new recruits. Of these, one out of every 67 died as a result of influenza or related pneumonia. Given no chance to breath a sigh or regroup its forces after the first explosive wave in the fall, the country was engulfed in a series of recrudescences. These generally proved to be somewhat milder than the autumn wave, with an exception seen in certain cities which suffered to a greater extent than during the first wave. Pearl found, in his study consisting of 10 cities, that 65 per cent showed two peaks of mortality, the second seven weeks after the first, 20 per cent showed three mortality peaks, and 15 per cent showed only one mortality peak. Thus, in summary, the United States* virst contact with influenza came in the form of a mild episode in the spring of 1918. The severe phase, accompanied by high mortality, arrived that autumn, and a generally mild series of recrudescences followed in early 1919 and again in 1920. All in all, the epidemic clinically affected twenty million people in the 2 United States and was responsible for a half million deaths. Vaughan, Victor C. and Palmer, George T. Op, cit., p, 592. Wyeth Laboratories. Influenza 1957, 1957, P- 28. 3- . ■ n-'-s . '• f t ,* a i . r r; ■, ;• . • i: a f • • * - * ' 'a J n< f.t .i t , c S © , •■■ ■ "1 . ■J-'ftf )i ;.® .v J < ,;.L • .3 I a j - . ' a ■ .■ 1 /; i : ■ a; 'to o - a ,.r a ■ . :a:; . ■ ’ ! . ■’ .o noil ' ! - l . : j a i i ' . • ■ a ' f n ) . ; • ■ • *• n n 7’ ..,ra -j • »: T r >■ ni . J- , ,/ u- : •' - i: : < *i .v; - o . j i •••.;*• • •• : ■’ r.'ic - - •: a; * ria arcf c;: a';io ■< tviv! j ■Ti t ,°i , ,r - -.‘.v ••• :t <1.1 •; 9:'! ' •v-a tjvlK i.:.' ) I •. ■" J ' ■ J • o • ' ■ ! j O •' y.i : J. L’ fl > ■ ;r a; ■ f acsi im rm ■ I ’ ■ to "i.. ? , I-J ,vo. J I -A ' J,;. - , f '• o. ; ina • . '• : > aiBeq -vu viva t »•:« i*a w ■ [' • r : ' • Hi -3'/ a ' :.f ? .a v --j a . a" : "o i -»*i* if 0 ;oai • r Ji: ■? a v ' ./ aia. . <.;• . .,-j. T- . 7 A < J: I'-.1' . ' - ' ' ' < ' •' 1 a/lCl , [I a: t< £ r low© 1 • i®®*x adiisa MJtr . j . o jo.tllJ 1 ( i > tnJ i • ' . ni : 1.1.1 - ... i ■; j ■ acta- • 1 J.lU .( , j : . H- •• . > .'a i. u r i ,n ( V . a. •*' M'-'X.V 5 9- Chapter III The 1918 Epdiemic in Easton, Pennsylvania As an example of the effect the 1918 influenza epidemic had on the life of a community, I have chosen Easton, Pennsylvania. Being a resident of this community for'25 years made it possible for me to gain ready access to town medical records as well as to those of private physicians who served the community during this epidemic. Easton is a quiet, medium-sized, town of approximately thirty thousand people, located on the west bank of the Delaware Siver, sepa¬ rating Pennsylvania from New Jersey. It was founded by Thomas Penn, settled by German settlers, and played an important role in the develop¬ ment of Pennsylvania as a colony and later as a state. In 1776 Easton was the first place in our young country to display a national flag containing stars and stripes. This original flag is now hanging in a place of honor at the Easton Library. In 1832 Lafayette College was founded in Easton, and the town grew culturally, industrially, and agricul¬ turally until it soon became the county seat of Northampton County. Being close to New York and also Philadelphia, Easton in the nineteenth century served as a hub whence the state's coal and steel exports were shipped to both seaport cities. The following report of the influenza epidemic in Easton in the fall of 1918 comes from descriptions found in two Easton newspapers of the time, county Medical reports, and from word of mouth passed on to me by physicians who played active roles in the epidemic. The headlines of the Easton Express on September 20, 1918 read, "Attack on Yankee Lines Cost Huns Many Men; British At Outposts Of Germany's Strongest Positions." The war in France now occupied the front ■■ • ,1 r 1 . ■ j 1 •?rft a fv/ri i ; ■ r>L! * ch r; -rlJ to •:. t. a r.:o a*- ! : ,j;> : , -,J .l.v '• ' - ’. i..- o: • ■■ . /r n > : > * . i It / •• ,t' ■ •- .. . ' tv : f n i c. ... ‘ t ' . ' 'i . . ' I 1 ' O . ■ i 1 ' ■> :.o* ■ <• ii j . " f, ■ ac ' 'r . j. a» • - - * • >5 •Ja,.K ) rc i:' -1 *- tH ■ :f-l ' r v. J <’.nl ■ n.; .) J ; 1X0 • fi; ■ •• ’-f ; ■ ' . r. • ■ . . ' J) 1 . -i- 'i ’ J ' i • i . . a ' n j. I • • .1- -w > ' 1 ■' 1 “X " ' V '-i - 1 u I . . > - j ’ • .... — - • ' • . ■ ; ;l ■*. X • o:. ‘ > i ■ > ■ ■ > 10. page of every American newspaper. By the 1th of July 1918, a quarter of a million American troops were engaging the Germans in the trenches of of France. General March announced that already a million of our hoys had embarked for France, and movement of the second million was being undertaken. The war was now at the doorstep of every American family. Colleges were closing their doors and forming training corps. Local sports heroes were being followed day by day with their respective com¬ panies over there, arid the people at home were doing their share by ob¬ serving meatless Tuesday and heatless Thursday. The Kaiser had not for- seen the ability of this young country to mechanize in such a shor time to meet the challenge of the German war machine. Far at the bottom of the second page of the Express there appeared on September 20th a fill-in article that bore the odd inscription "Spanish Influenza." The article went on to say that one of the Haffey boys of South Easton, home on a furlough from Camp Dix, developed a mild case of what was thought to be Spanish Influenza. Bill told his family that all the boys at camp were sick, but not to worry. Bill returned to camp, none the worse, but soon his two sisters were bed-ridden with the same sort of complaints. The column was longer and the type bolder by September 25th. Thirty- six deaths, Bill Haffey, among them, were reported at Camp Dix in one day. The total for the week now stood at 96. More men had succumbed than had died in the entire previous history of the camp. Additional army surgeons arrived and were assigned at once to relieve the overworked base hospital staff. From Washington came the announcement that the government would mobilize special medical and nursing units to stamp out influenza in the > 1 :0 ' ' 6;i r X.i a.’-.r •;■-.•• a l r . v - . r- ■- > n < • ' no ill!/ ■ iff ' .: •> "111 rv:- >. .• ;* •... . •• • i :o <• I • ■ in .•>:.'£) '' a * * ( ,. ' , ■ .!■ . , '■? V i I ■ ” • : '!■ i" ' i ,.-fj "i l > ' ■ ■ .<. ’ - ■>' -> - • ! I " • ' : 1 . '• ■ ^ '■ • '! ' ..i . • ’ 1 i ' , i j . • » • i j , ■ i . . •' i 1- r - /• t - r ‘ j |o J ■ T i i l j . !. - • ' o > • Ci ; ■ * . .i - *' ( . ' ' r. -i 0 f >' r < t tr! .-j"> , a , n if:on: n a ■ '■c -1 w tiT'V ■ . . iliiii r oo • I f o ' • .■ os. x "> o: ■ n . .1 V , .:a*(.Lo: •.m:.’ j », o ■ ■, • 1 ■ ■ • ft t M '! "•O'. I' ■■■ 1 . • 1 T ' • ‘f / i • . , ; ; , I ' ' 1 ' ' ' ' ' • "• ' _ • • xf 9000 d n : ' " n Hi: ■ j .J ■ • nCj <; •• • I _-,u J ; . • i » -at*- o-:a • ’ J- i ■■ ; * >1 - 11. camps as well as at home. Provost Marshal General Crowder cancelled the call for entrainment of 1^2,000 draft registrants between October 7th and 11th when the death rate reach per cent of new recruits. From Lafayette College in Easton came the report of 80 mild flu cases among the military corps. Captain Parker, camp commander, cancelled the annual military ball, highlight of the wartime social season. The students and military personnel gathered on the college quandrangle to demonstrate their vivid disapproval of Captain Parker’s decision. The following day 35 more new cases reported to the infirmary. The Pennsylvania State Board of Health called an emergency meeting September 28th to discuss their plans to fight Spanish Influenza. Dr. E. M. Green of Easton reported that from his personal experience the victims were generally in their teens or early twenties. He said that the disease was unquestionably spread by persons coughing and sneezing. The best thing for a person therapeutically was to take a warm bath, go to bed, and send for the doctor. The type was now bold and the columsn long as Easton seemed to be in the grip of the disease with four deaths reported on September 30th. Hundreds of cases were reported, school children remained at home, stores and factories were operated with only akeleton crews, and Lafayette College was put under quarantine by Captain Parker. Easton Hospital announced that it could only admit emergency and accident patients due to its crowded wards. Congress now appropriated one million dollars to stamp out the disease. An Easton doctor reported that deaths from influenza were definitely associ¬ ated with secondary pneumonia. Now the people of Easton were beginning to realize that they would have to fight for their lives at home as earnestly as their sons were fighting in France. J' . . , ' . './• ..) I •; :: '/V -)V •' ;r , , -j 1 . r, :' • '■ t- . ‘ Jo ' ■' • n> ,io . v • • : - -.o , i t 'i • i .j ' * * • ' 3 \ . ; i J "ici: ; q r. T ■ • ' ‘ ■ r : ; • 1 1 ’ ■' : TO , i r r , . n ; . l »' )' ■ i ' \ > ’. • ■ j . • i ,. . ■ ' .; ■ ■ . / • ■ ' ■ • ’ •' ' -J ■} o' ■ ■ *. >< • ‘JO > •' " ST ] : j'ox . , ■. ■ ;■ ;'i v • '1 - : rioV, > • : ' . ' ’ o ; c, . • ■ ; r: ; J . ji" r v: . ■. ■ • n :o'-0 . K .1 : , , . JtJi vj ,i • 5 o r - - • . - i n *: n ,i: ; ; .■ i . r. ■ : i. - * , <’V 1 M .v ’ 'w n . ol , . / o : if- ;-c■ i no c... it'l i • , . . i a .i » 1 tl •; :. ,!• .-|q . ■> • ' ■ ■ •>'; f U' . • V. ; r » . v i . Mw ■ 'O'' -1 ■, » j • • ' : ■ - u L- v ■ i ' . i ■ ’ J . - V t . . -U o r ; i t"'nr . > i j ,■ .j ij .i cJ icI a ■ r»c i *• one <* r . • . J i. • v: j' . : J xt 'O' «• d: x; ■ • ro > ' > : n * , ■ i- i o , ' , i io - 1 » o '• o ■ • ' • : n ■ i .i: u ' ■ i' x i " i ‘ - 12. The first day of October 1918 brought hope to the hearts of American families. They read that Germany was on the verge of internal revolution. Huge crowds were reported staging peace demonstrations in Berlin and demanding the ousting of the military oligarchy. In addition, other good news greeted the Easton area readers. Dr. E. M. Green reported that the flu epidemic had reached its peak in Pennsylvania. He stated that condi¬ tions were not as bad as the grip epidemic of 1889 and 1890, and if the weather remained good, the disease would soon disappear. Dr. Green went on to say that the name Spanish Influenza had been given to the epidemic, but doctors agreed that the disease was unquestionably the same as had been known by the names German Influenza, Russian Influenza, and La grippe. It was caused by a micro-organism, and was spread by coughing and sneezing. Five more deaths and a hundred more new cases followed this report. It was now plain the epidemic was far from over. Easton's City Council along with Mayor Nevin decided, after the report of eight more deaths on October 3, to close all theaters, dance halls, and saloons within 18 hours. School authorities were ordered to send home all children who coughed or sneezed, and trolley cars were to have at least three win¬ dows open on each car. The following day these regulations were made state wide by the State Department of Health, and were extended to lodge rooms, bowling alleys, pool parlors, and churches. The board of health distri¬ buted 1,900 placards throughout the city, illustrating the proper safe¬ guards to prevent the spread of the disease. Thirteen men were arrested in downtown Easton for failing to observe the anti-spitting ordinance. The men spent the night in the city jail. Wine were released the next day, but four remained to receive medical treatment for influenza. n ■>- * t'. ■ ’ -r1' . ; Of' J . : >KO + ivr .1 -j H r.; -I :.)> a '.v-« .ii. . : r i ,u . '-Ki/: , IL, . -i • >. J -. ' "i‘ ■ •>’ • O'! Cjf . ao' CJ J o • arc ».'* .^n.i ,,n: V i n;i ; • ■ : y ■!/->•■ ■ : ' * - ^ < ■- « - ' ir ■ n . ' ' ■ ■ v' ; J . ■< '/ ■ L ., s'. ■ ;i'i v:j:. -v ,.a<. ■ r - !■ .lO; : .:■ < • - : i ~ :• '■ ' V •£>'■' 1 • ■ 1 ' ■ ' I .1 " ' .. » ■ J t • ’ . i.i n . ' ".l n - r; i • - -i;, ' ’ -i - •" i tn •• -c ii. i 1 .j " i •* 1 *'"<■' '' , wo, r -f c .1 - •»! /- • Y‘ “3 ' *• ,»;■ I: - ’ ' i 1 ■ '• j j \ i r , jo'i > ■ ji : a' -t- ' i • i" -• f- •< ’ V oos „ a• 1 ' ■' .■ . "rtJ ■■ - J i • ■- ° ' t . j-. ■ ' » . ■ r orr , -i, ji ■ ,rr: • ■ ' -A .> ■ •: 1 . - 1 u ' . - ; ■ i% l - • . 1 I » 1 ■ > - ' - M-.JW - r ■ . n • . . r' ,, ■ •-!■■ •!-; U :v; ■ . t > , •• . ... ■ r. -r.. • ,w .r , < . i ■ ■' ' ' 1 ' ^ i u • . ; - ■ . ' fjr^ a . a i - •" -*-• ' - ' • f o*i^ . a- : - ' I : i - ‘ i - • " • ■ - ■ 'J • j* i n." , ■ : i o ... j n J nj i I • . i r; • iv-oc ; ) a.'' a ao ••.’ n o' ■•a - two Jm./oI .ii . n -. ‘ i Ic-'j' • >w a ‘ .'i . I’ v,i; ^ ti -*'• ■' * • ‘ vvik • r;' '.v •; j -oil ^ - vi ,• .-ji ■' z i -. /on 13- On October 7th, the Kaiser’s peace plea shared the front page with Easton's call for medical help. The local physicians were now unable to care for the increase in new cases, and the call for aid went to the State Health Commissioner, Extra forces had to be hired by cemeteries to dig graves, and a coffin shortage arose in Easton. The following notice appeared in October 7th's Easton Express. "An Urgent Appeal to Every Woman in this Vicinity” "The help of several hundred women - their personal help - must be had immediately. Women to help in families where there is influenza are needed by the Bed Cross AT ONCE - needed as they have never been before. Experience in nursing is not necessary. You are asked to help distracted families unable to secure assistance of any kind - to look after children - cook - give worn out father or mother a chance to snatch a little sleep - to do the many things that only a woman can do. The concentrated action of several hundred women will stamp out our epidemic. It will mean personal sacrifices and discomforts, but we believe this call - in the name of humanity - will be met by a prompt and willing response. Call Mrs. E. P. Williams at once - phone Easton 19573* If you are unable to give a full day come for half a day or a few hours - only please report promptly. If any one now employing nurses can release them it will greatly relieve the situation,” "Chairman Bed Cross Nursing Committee" , : ■■ C 1C r / . C • . =0i c . . :y ■ ' c: j mu :• i .v c .• '-i - • : ■ ; ; i Xj i. •; i, • J rt ' v-n ,.i ■ v i • • • ' ' ' ' ' notaelnffij ■ a . . . c i 11 . ■ . * n : • n ' . c J ■. j c, ’. . i ■ J-.*■ ; : f : l.i: -V _ o n " v .■ v n . * r •?!'.' .. *5 •. -v- ro q . .c . i' •' •. • .1 ' ■ t* , i • ' ;j‘.< , Li ’ • . V ‘ I ■ " '! '1-i- ©•;< >'1 w .1 -j tc • c v ©n v rri. ur c b-; 1 /? -i vc-a 1 ' im ll - i n: n i. ~ „ , • :> • > ' j.. .. h- ; i li ;i vi f J '. j i ) , tor. O j TC • - J ’■ ViO.' ; ;>J .rij .* C f i'"J c . ■ J • O' r. o , i iy.r ■ -I < . •; i_ • i i ’ ■ ni > ■ ‘ > .'< to M . X.; * : .;a . ,C.' ' n / i v ! ".•co A' .si . i j ) III v/ rl ■ n * . iic <*•; i n ' i Orri ■ r . ^ i , :r. a- - r.o Tc- • f • < 1 ' • \ \ i. ■ ■■■lari c , . vv: 1 ■ iw "• -jI( xu .c- ivv >■.. re -1 ' v '-L . .0 • A ‘C • if >i X.. ; . J.i i iV ■O-S'.un .n.'xoJ>r « ’ ';ao n J. jtir «ri : I .*• ?,a.l > M.cstll .ll UC •• -VC" : ’ .1 11} :‘-r In the same issue of the paper Dr. Royer, State Commissioner of Health, dispatched this nessage to Easton doctors. "Physicians of Easton take head: In Massachusetts pneumonia is less prevalent among influenza patients in canvas tents than in hospitals or private homes. Fewer nurses, doctors, and attendants sicken under canvas. Listen! Give in¬ fluenza patients open window treatment, and where possible outdoor treatment." Advanced medical students from Philadelphia medical schools were sent to Easton to ease the doctor shortage. Along with the fall of the Hindenburg Line and the decline of German resistence by October 9th, there seemed to be for the first time a parallel decline in the number of new influenza cases in Easton. Even now, however, the large number of cases necessitated the turning of the City Guard Armory into an emergency hospital. Area physicians were urged to report all new and old diagnosed cases of influenza so as to enable an accurate count. Florists of the area published their regrets that they could not supply ample flowers in view of the large number of funerals. The following day the epidemic situation in Easton was described to be at a standstill. Dr. Green stated that he thought the epidemic was now spread¬ ing west leaving Easton in its wake. Up to October 11th the record read ^9 deaths from influenza in the Easton area. City Hall reported a new complication associated with the lessened epidemic activity. Aside from complaints about several saloons remaining open to sell drinks, Dr. Condran declared that there were many noticeably drunken men about town. This issue was sternly dealt with by Mayor Nevln who immediately closed all breweries. The new case rate continued to decline for the next few days, but death rates were still high. On October 15th the newspaper re¬ ported the largest number of deaths per day in the history of the city. j rmriv J .t" „'rvv.-„ .rtf! rc .o x.t sr.: i; ) H 1 : - ' - 'i r.u ' v ' r! . ' ; ■' • .. 'i . : ■ . :.v . ; , .le-ii-r ■{ i< nMf sfnetf . v ii. on - , "i O'' .3 ... . • . :. 1 - - i r It U I 0 M . r: • ' ' , mu v.Tj I 1 '3 .' 1J f: j t r !■> : ‘ . V >o ni ; . yi’.' n ;i; • v r J.i - r a* ~ •:* i " i. j 3i-I- of r:f ■ ;'G " fi - o 0 .nets i -i rl » • • ci ia - - M •-ftlirL'jf . in V. • • ■ •: /.:•’! '.‘rs.f .’XV-xnr .'- Gil . i 0 ft a r. 1 • ■ 1 . V . . • ) -.1 ;• n.\ bo j .> .. r v» 'n f'.-X V- j , j ■ ,1\ , ■•. :■ i - , •; ,;t ' v i' .U^x ( . I Xu ....t o i- . ; . c ’ o ■■■:• ■ i ...I..;'--' .: >' •• - f ,t vf ; ij j!, • .; I j I T - .1 «fr ■ n - o' 0; ■ ' ’ ’ n:.i i 1 .. j ’ j o'. i""'i f 'K-’; ,lRVf ii , y t,'f i . .1 .1' 1 .i "-/ f. . ■ l-y. 1 . ncit- llCftUCD . ... o: : fj a i . ! . iPoev . J w : i v ao-.- . . : -f . ■ -■ • ■ . xi , i t - .i' - w , ,;-J %o .1 i . t ... fn.) /r;c- -9». 'V.‘ W‘ ■ ’ W 'It •’ - . • ■;v,i"oo O', t VG'.I r . fi jl/< .1 .t. i' - x x ttr"' ‘^“b •; , t) ■ . ; J B ij aJfc i • n : ■ The total number had reached 111 since October first. Wholesale liquor stores were closed to tighten the quarantine, and beer was sold only by a doctor’s prescription. October 18th saw 112 new cases of influenza reported. This was a decrease over the last week, but still too serious a threat to relax the quarantine. A kind retail liquor dealer in the city provided free whicky to all the worthy sick upon presentation of a prescrip tion from their physician. The prescriptions were filled at City Hall under police supervision. Citizens were asked to please bring their own bottle and cork, and limit themselves to eight ounces. On October 21, for the first time in 28 days, news of the influenza epidemic failed to make the first page of the Easton Express. Twenty- seven new cases were reported Wednesday, October 23, with one death. The total deaths now read 197- On October 2h no mention of the epidemic was made in the paper, and on the 29th the epidemic was felt to have left the city. The people of Easton, quickly tiring of the recent restrictions, pressed hard to remove their quarantine. The official records totalled 860 reported cases of influenza with 2^0 deaths during the month of October Easton cemeteries recorded 150 burials during this time. On November 7 came the lifting of Easton's quarantine marking the end of the worst disas¬ ter ever to engulf the area. Ironically the quarantine was raised just in time to celebrate the end of another disaster, World War I. Peace came to the world November 11, 1918. The epidemic left Easton on November eleventh, and soon life was back to normal among the inhabitants. Many will never forget the loss of their loved ones, but few realized that they had experienced the most catastrophic outbreak of infectious disease in modern times.^ In the United 1 Burnet, Frank M. Some biological implications of studies on influenza viruses. Johns Hopk. Hosp. Bull., 1951, 88, I37. . ijj'*1.- .-r : "x.• >' ’.U toria/vn f>n * \ , ■ v •) . •:• : J.. -: i; ■/ . a . ! j. ■ ; i’.o s. r j o - v .i • . ./ ' -.0 5 ■ ■ .o i.Jq1' * . vV ..o' : ■ oj a . •? - -v. ■)**-,..it: ■ a.sw . J>«: Kobe's ! .... • . X . till; -ti/a 1 T • 1 ' • < * a i. :i • -i ■ M i. •; . ■. - ,o . ■.! ,. v !...•' ■ ’i • • a ' ■ m . ’ JtO sr. ©*sev anoiJc t~ ' ' 1 X • ' a a Oj •. >' o i : * •' < i • i‘- ■ a, ' ; oj ;.J . .■ r : 1 . a . t VOa a" ■\t ui.lnt «n> lo $ ,:^ei) v al taut#. S - T.t*t »f *»1 ,l(: "tirio&oQ a< , 3 '' ! ■ ' J <' - i ■ ■ . ■ . tv. 't j W o ■ - ■' * a w-aj j •■!:.: j' J nr Vt n. ■ o . ' » ■ o !* . r : *• Oit ►. no ■ ..t'j C.i : -> O'. . : • , ,ji .• o 1 1 ■ ’ 1T l .(-■'•,0 ■ J a • '5r Uv-; " 'M,.; ' ,C- I ' i<■ ■ ■ -- '■ ! Vi M I a"-, a; • . •• :C n oOa ■■ ti ■ ■ I' ■ <5 '' * A ■“ al ■- I - ' • • - 1 ' -a - .a : v jVi '.o j. • - • oi .ailt a .Oj-o. ■ a ► , V.iiw. \ i ■ .i. -i< • 1 :> ox ,5' ... - v ( illw n A . ui“ ^ u :• - j -no, . > •-5 J -j- -..HI ;i >■ . a ■ <•• ; . ■■'. ■ J i . • .'.0.1 J."< ' j a. ^. • >;i2 > m ; i j> o ■ ai H - t‘ir v.-' •• •. '.-rstr.x" U i. 'U.1 ’ o '.lo-iv t...qrii •, i«:-c . ‘ - • .j,;tr-Oc . 'CX tes t - , .i::i£ . a:;: >T . ■ ? ' 16. States the average mortality was 39O per 100,000 people, hut variation was considerable from city to city. Variability was also a fact in the number of incidence and mortality peaks in different cities.^ A so-called minor epidemic followed a year and one half to two years later, but in Chicago, Atlanta, and Kansas City this minor epidemic carried a higher mortality rate than the original 1918 episode. Burnet, Frank M. and Clark, Ellen. Op. cit,. p. 75- f : ■ . : . ■' ..." ' * •• ' ' . ' • - ' • i • ■ ij ± "t i ::1 ocro .t-' : >w i / \ ]. 'i;i •> ' t ' ' ■ ' f - 1.':. . ■ .l ■ ■ ,i' i.'iO n :I" ' J - j .. . . •-"J ; n . . ar • 17- Chapter IV Influenza Investigation Medical observers now began to look b8ck on the epidemic and found to their surprise that 50 per cent of the deaths were among the 20 to 10 year age group.^ Also surprising was the finding that case incidence 2 was highest among the 5 to 20 age range. Various explanations were offered to explain these facts, but only postulations could be made until the development of more advanced investigative means. The first and uniformly mild wave of the epidemic which appeared in the spring of 1918 was studied bacteriologically. Pfeiffer's bacillus was not found in a large enough number of cases to be considered the etio¬ logical cause.^ This was in contrast to findings reported during the second wave in the fall, during which Pfeiffer's bacillus was reported 2i in 70 to 90 per cent of the cases, Shope stated that while some investi¬ gators were convinced by the 1918 bacteriological studies that Pfeiffer had been confirmed end that hemophilus influenzae actually was the cause of pandemic influenza, most people felt that some other explanation should be sought. Attempts were made at this time to demonstrate a viral etiology. Selter and Jaschke in 1Q18 claimed to have produced influenza with bacteria free filtrates of upper respiratory tract secretions from human influenza cases. Most of these experiments were largely negative, and were unrepro- 1 Burnet, Frank M. and Clark, Ellen. Op. cit., p. 79. C Smith, David T., Conant, Norman F., et el. Op. cit., p. 732. -3 Shope, Richard E. Old, intermediate, and contemporary contributions to our knowledge of pandemic influenza. Medicine (Baltimore), 1911, 23, 426. - ' “ McIntosh, J. The incidence of bacillus influenzae (Pfeiffer) in the present influenza epidemic. Lancet, 1918, 2, 697. 1 x* ■ , , l >v i . ’• ",:i u , i',L '!*••• i m )' ‘>,j ■ • '■■■■;■■■ .-.o . >i . - ) ■ / . o’’ •> . i a J . ! i ' ’ - ~i I" C j‘ • 'I . • '■ ' u,: i • ' • •> ' ,. ■ • j - . < ' h ill i • ’O ! . i -• .• rj 7 - ' -1 0*1 ' .1 . , ■ v i - .. i; j ' . .i ;■ i -• • • i.: n;i- i i . . J: i ' 1 ' i v i ' l ' ' J ■ J, . J ' • 0.1 ' f . ' a :r • . / . i • .• it i I : : ii' a ,;.i .. a1 - a '-0 .if. • / ; > , v-. IS y > j ' '■© ; , i . r f a l 'i I -a' > ■ , 1 .■ jr < :t • ■.; . ‘c ' -■ 'i » ' •< 7 M 1 -I ; ! . ; - ) : j T lOi » i ; • i ( ■ ' ' a '" - ( n:o , • ( • • ) „f r. *;j a a n i • • i- • ‘ . .f rj J .1/1 A> * ■ ii ..-J' il -v - io 18. duceable by other workers here and abroad. Speculation was high neverthe¬ less, and most thought it to be only a matter of time till the etiology of influenza was determined. In 1930 Richard Shope described the presence of a filtrable agent in infectious material from cases of swine influenza that had definite 1 pathogenic properties for swine when administered infranasally. Subse¬ quent study showed this to be a virus which was indistinguishable clini- p cally or pathologically from the human form. In 1933 Smith, Andrewes, and Laidlow successfully infected ferrets with bacteriologically sterile throat washings from influenza patients. The infected ferrets developed an influenza-like illness, and it was found that this could be transmit¬ ted to healthy ferrets. The causative agent possessed the characteristics of a filterable virus; thus at long last a laboratory animal was found In which the disease could be studied.^ The infected ferrets which recovered developed an immunity to subse¬ quent infection with the same strain of virus, and human serum from influ enza recovered patients neutralized this ferret influenza virus. Thomas Francis Jr. was able to reproduce these results using as his source human influenza cases in Puerto Rico.1' Shope' s swine influenza created an influ enza-like symptomatology in ferrets strikingly similar to the human type ^ Shope, Richard E. Swine influenza. III. Filtration experiments and etiology. J. Exp. Med., 1931, 54, 384. 2 Idem. Old, intermediate, and contemporary contributions to our know¬ ledge of pandemic influenza. Medicine (Baltimore), 1944, 2__, 432. ^ Smith, Wilson and Andrewes, C. H. A virus obtained from influenza patients. Lancet, 1933, 2, 66. 4 Francis, T. Jr. Transmission of influenza by a filtrable virus. Science, 1934, 80, 497-459. >X1 ' i • v ujL'h-’'. c-- i J - n\ ■ ... tBitaJ -' 1 ■ . < •. ■ a I nl t . > r f Pi nl .anct nexsurf orf* *00 v t; ^ to y.X . ■ } . I 1 - t ml . E • ■ ' . -i ill, ;,cv .i,• t- . o; 1 . . Ir-it: >u i -I dtt I ' Xtiw it.1 < .( :■ f . j: ; <- "‘-/i > : .’- xi.L ’'. t. ‘ j ' . . a ■ ■ I . ,oI U - c ' ? j .'J ' : r> • • ■ i" - -•>- , (■ . 2 ' i ' :i r. ' v i • ' r • . ' (5>:- '*r • ' ■ 1’"‘ ’ j ' it lo no .' ,(2-" t £91 . a"» ■tr." 19. suggesting a close antigenic relationship between the swine and human , 1 forms. These advances fostered new interest in influenza research, and many workers began to add their contributions to the field. In 1933 Elford devel¬ oped a gradocol membrane which made possible the first relatively accurate measurement of virus size.^ In 1936 Magill and Francis found that various strains of influenza viruses were antigenically members of the same virus group. Serological types similar to the original strain isolated by Smith, Andrewes, and Laidlow were designated as influenza A.J In 1940 Thomas Francis, Jr. described an immunologicaliy distinct influenza virus, and 4 reported it to be type B. In retrospect it was felt at this time by most workers that the mild wave of the 1918 epidemic was caused by the type A virus, and the more severe autumn wave had as its cause an immuno- logically related but not identical etiologic agent. There also appeared with the severe wave an unexplained pathological relationship with Pfeiffer’s bacillus. Hirst, and independently McClelland and Hare in 1941, described virus hemagglutination as a method of group determination. F. M. Burnet e 6 T in 19^3 discovered that viruses could be cultivated in embryonated eggs.-'"’ ’ ^ Smith, Wilson and Andrewes, C. H. Op. cit., 68. ^ Burnet, Frank M. Op. cit., 119. " Horsfall, F.L. Jr., Lennette, E.H., Bickard, E.B., Andrewes, C.E., Smith, W. and Stuart-Harris, C.H. The nomenclature of influenza. lancet, 1940, 2, 413-414. 4 Francis, T. Jr. A new type of virus from epidemic influenza. Science, 1940, 92, 408. m Hirst, George K. Direct- isolation of human influenza virus in chick embryos. J. Immunol., 1942, 4^. 299. r McClelland, Laurella snd Hare, Bona.Id. The sbsorption of influenza virus by red cells and a new in vitro method of measuring antibodies for in¬ fluenza virus. Canad. Publ. Elth. J., 1941, 32, 53O-538. 7 Burnet, F. M. Propagation of the virus of epidemic influenza on the developing egg. Med. J. Aust., 1935. 2. £87-589. a • ■ •... ii‘> •' > . ■ . ' ’.n n oi • i r. . • • 'i ’ • ' i 'i.' ■ i ’ • r, ■•'/o’ ;• n - ■ : - • ; . . . > - u: . ■/ 'urr. ■ ' ; + / J x • - i' c ‘ r L > .. . >.• u J i J • - . v ’ . 1 ‘ r i ' -I 1 U'O' •>' - . "O '■ X . C I' - rj ■ • ' v tl * : <' ... n - '.'i i L ■ ■ { .••••' . i - - :. . '.1 • ■ i- ' . s < j ~>j j • ■ >' •• • ... o. . . .* • i ' O ’ ' ’ "l J -■ ■ K j 'X 1 , • • . . n .a-' . i;. u-.il 90 • . . a :i ' y r' •!. ho- i'. y < - al t •' : \ • t , i: 1 . ?. ■ ■ H . ; 1 1'' , V ' 5._ . . .t‘f .(^ . . j IV J . ...... tmats > " .j *. i. - • ' • . J .. • ■ nl ...... • -. i . i • t jl . !■ r: • lv •. -u k | j •' • - 20. This trade available large quantities of virus for experimental study end vaccine production. With the advent of penicillin in 19If2, systemic anti¬ biotic therapy was available to battle against secondary bacterial infec¬ tion, long thought to be the prime factor accounting for the high mortal¬ ity rates in major epidemics . - 1 I . i ■ 1 .. ■ : ; • , -J , * • ? . - ■ ■ i ; " -j r. ’ • • ■ 21. Chapter Y Influenza 19:7 Many now seriously believed we were at last prepared for influenza. We were aware of the etiologic agent, we had means to provide immunity, and we could protect against secondary bacterial infection. All that now had to be done was to detect an incipient epidemic, and bring our forces into play to combat it. This exact situation arose in Asia in mid-1957. Our virologists, epidemiologists, and public health teams instantly began work to identify, classify, and prevent. It was found that the causative agent was a new antigenic strain of influenza virus A. The clinical course was generally mild, with chills, fever, aches, prostration, and coryza constituting the major symptomstology. The incidence in Asia was approximately 20 per cent of the population, mortality about 0.1 per cent, and most deaths occurred in the aged or debilitated. Thus the attack and the mortality rates were estimated to be much lower than the respective fO and 3 per cent in 1918. The dif¬ ference was accounted for by the fact that while the causative virus (Type A) was probably the same, the strain causing the earlier outbreak was far more virulent.^ The medical profession felt at this time that vaccination constituted the most effective method of reducing the incidence and lessening the severity of the oncoming epidemic. Experiments indicated that such pro¬ phylaxis offered approximately 70 per cent protection. Because of the short incubation period of the disease (1-3 days) and the approximate 1 Mattia, Y. D. Jr. Asian influenza. Therapeia, 1957, 76, 2. ■ . n - :j i I t-r t.. o'" i • ■ 'V . '' -r -- „.i 'i .;/ ' rv- .i ■’ t- * l.L. .■ ' - v >' * \ -i ■ .... ■ or; r ■ ■ . : 1 r< ‘ o : • .v-.o . ; J • n f | • , . ■ > i j ' ■. ' or ..) 1 i t !.j I. • : - ' 0 >:i .) - . _ j ; . ‘ , ■ • >' i • .'! ' i" ... V ; V r ' * ; u ’ v , r:i t ctJ t ' / • i ^ • . ' c; ' ' : ■ - 1 •’ - 1 ,: > ; , ' ■ 1 i: • •f. . • *>** • : r ; .! • cu /;:■> ‘-*t j ’■> '-f-O'u . .1 ' . i I. • ■V 1 ‘v'i • • , ■ [J , o ; 1 r • ' , ’ ■ - ’- o) v 1 ■ ... - . ... > - > t . ; .M i - ' , ; i ( ■ i, )j 'i •< ' ' rP : ■ ' " . •' ■iH !- " ■ *■’ •;>- ' ■ rag uc icMoae ai# sal sue? nt& : Uf ’• .OC! T C -"it no. i ■! J ■ ii >/)•*<• : ' T ■ no! • ,0’ , • : r: •-n ri? PX J . 1 ■ ! T"' . ' ■ - • . ■' : ’ ' ■ "■> - ■ i: - ■ Ur. , (j . 3 n!Uli r,t a?*’ v . is i '.5 -mI ‘ > ' , ■ ) ■ • •' ! t ^ V I •* '' '• • [ iJ net i /' • • "L . ' ’• ♦. t i-* 1 > 22, ten days required for immunization after vaccination, the program had to he carried out in advance of the epidemic. A multi-million dollar program vas begun by six of the nation’s leading drug manufacturers to produce monovalent and polyvalent vaccine containing inactivated virus derived from allantoic chick embryo fluid. The vaccine process proved costly and the full manufacturing cycle took approximately 50 days. It was found that the vaccine had to be refrigerated during shipping as well as while in storage. The vaccine underwent chemical breakdown if stored at room temperature for more than five days and was as a result ineffective. Under refrigeration the vaccine remained effective up to 18 months. The success of the vaccine program to curtail the epidemic depended first upon the efficacy of the vaccine and second on the number of persons vaccinated by the time the epidemic struck. This 1957 program constituted the most comprehensive effort ever made to prevent an influenza epidemic. Shall we look at the results? As was the case at the beginning of the influenza epidemic in Easton in 1918, again on October 1, 1957> the headlines of the Easton Express described American troop activity. The dashing exploits of Pershing's expeditionary forces were now replaced by the more degrading and dis¬ appointing news tha t federal troops were necessary to make it possible for negro students to attend Central High School in Little Pock, Arkansas. The paper also stated that during the week ending October first a sharp increase in school absences had been noted in the Easton area. Pealizing the importance of early detection and remembering all too well 1918, county health officers ordered immediate tests to determine whether or . ' : ■ " - ■ 1 ' ■ '■ ■ ,v. i ' h ■ :■ >: o*... . ; m ' •" .n < ”i. ■ V 2 • n . ; ';o :iir i ■ v. • . r ■■■- i'/ t .J.! :i ■ ri\ »--votxoc: f- • . V j .• t . ; ■ ■: ■ | 1 . It > 4 ' > ' • ' til J {, •; .1 0* y. " y<>- ■ ' • ' o. ■ . Lev ft! : ■' J " ■ ' ’ . ’0 a lr 1 ' . ii (; -■ x uv y.z"‘ » i rti . •> ‘ : ■> i .•> • nor. ne • o ' h t'- ct • r. / t • . ,.l t ;v. J v. f ' . ;|t. '< 10 i vlO hl'K" i O: O 0 n.t.'OSlV n ■ "j- r- 'cn ■ ii ►> uJ , ■ o •• ■ o J i: . t ’* , ; •• . w a ■ n ri,r . if •»:. »■ iv;o 3'i-t V !J ill -O ' .! • ' * ' n ' r I M 1 ’ ' • - riJ ' CO . •' M .U >'-• o ■ >1 '*'• ' ! vr:; _ • 11‘ v V •• - • If won r. . • ::no; *'a t ? ■ ; •. / . ■ -i-a-M iqcc- ; i • •••; : rrJ ma mil :Jn,.c • r- ■ • ' (i. o ■' . f a'iito 1 - . .-i o jl« '• • _ ■ \ ■ ■ od . .' ‘' - rl v T , !J • 1J C j J . yt r 1 iO • • t.T: o I t ■ .1 v .MOO 23. not the schools were dealing with Asian influenza. The case incidence according to medical observers seemed to he highest among, children and young adults. Many schools in the area began to close as absentee numbers climbed, and last-on learned that it was again in the midst of an influenza epidemic. By October 12th, Just two weeks after the first case reports, incidence rates began to fall, and some schools reopened their doors. The county health officials believed the area had experienced a mild form of influenza and felt that it had now passed, leaving no mortalities in its wake. One week later the incidence rate again rose, and Easton Hospital admitted nine cases of diagnosed influenza. The first death in the area attributed to influenza complications was among this group. By the end of October the hospital reported admitting approximately 35 cases during the one month period with symptoms characteristic of the epidemic disease. Of these, two deaths were attributed to Asian Influenza. These figures certainly differ from those reported by the County Medical Association at the end of the 1918 epidemic when there were 860 reported cases and 2l0 deaths in the Easton area. The lower incidence and mortality rates were explained by the state health officers as factors due to an etio¬ logical agent of lower virulence than the 1918 virus. It was also stated that increased immunity could be a factor in the relative mildness of the attack, but it must be mentioned that very few persons in the Easton area had received influenza vaccine due to a shortage of the vaccine prior to the attack. Easton was certainly more fortunate in 19^7 in its relationship with influenza than it was in 1918, but still too many people suffered, and Easton has much to remember. The County Medical S ciety concentrating on the preventive aspect plans a major vaccination program at first notice of the next influenza wave in Easton. J ■ ■ : a' - iL' : r\y.i a .i; ; r.[ a>' sw .Sv'O.ri’ ■ 1 J-<; ; u ’ -Ci<" ' J ; "J • < ■ V. !‘ •; i;,i r. : t; f .->■;) . r ? , ; • 11 'i ‘ J f j i •’ ■ ' !’ . 1 ' •' i i : , j ‘ • . / ‘Vi ’ ■ >' I' n . • i • ’ ft i I ' < , ' r . J »•,. i' ' T" ,'1*. i f ’ '. f ' it j f j / ■ ’ r • r ' • I ■ 1 . . 1 * • 'I : f - ! ». >• ' • » .. i f • ■ ii ; -* ■ I . ' .! . . t .. ■ .r*> '• o 1 ■ j •1 i- J ) . ‘ / i ■ i f. • n - - * r. i i a • ; ■ < / in. ! ;• j ■ V 1 ■ . < u1 . ; r 10 : r- ■Oil- n >■ tnu.:' • j • ‘ V- 04 JV. 'I • > - 0 '1 .. i. •• j aa ’ iO'. •, 0, dw : n>i : ;• r J - ! 1 ; J ' ' 1 [i 1 if i 1 . ■ r. >' i.‘. t .... (a' r >i ) 0} UP • f ■ ' > ■. r ; j V/ i «> < • > • v r • . u ■. / , j- . i r r • ! i v i y- ■ r\ j <• •to t) ■ -r i. c f X' ’ •■ti.i). • 1 ?; / v r . 1 • •t . i.' • ■/ ft : .i n / -i 1 r- 1 o 1 ' r 1 ; * ) f ri,«. u . 1 :J - :i ijI r ■ ■ , , • * i l f '5 t . o ::- J. i " i X . ■ ' ■■'.a C .* • • ’; r t j. y ; : .1 , >• > j iV £1 . i. . ‘Uf 'i > f v ■' vr v y' ’ r 1 ‘ rn i i n J :U i *■' \.i ,i' a . ’r / r During the fall of 1957 while in New Haven I personally witnessed and even became part of that city’s influenza epidemic. The following is a description of the epidemic as seen as New Haven Hospital in res¬ pect to therapy snd clinical course. The detail cited in the following paragraphs comes from a clinical study done by Dr. Robert G. Petersdorf at the Grace New Haven Community Hospital. The expected Asian Influenza epidemic appeared in New Haven in late September with its peak during the last two weeks in October. Throughout the approximately six-week period, 91 people were hospitalized with the diagnosis of Asian influenza. It is of interest that none of these had received any influenza vaccine. Among these 91 there were 11 deaths. A criterion for hospital admission had to be established to handle the sudden influx of patients into the emergency room at New Haven Hospital. Those with severe cough, positive findings on chest examination, or temperature elevation above 10l° were admitted. The hospitalization of the 91 patients during the six-week period constituted a six-fold increase in pneumonia admissions over the same period in 1996. Within two weeks after this peak, pneumonia admissions returned to the pre-epidemic level. Statistics showed the following: elderly males were more likely to develop pneumonia after influenza. Females were most susceptible to influenza during the child-bearing years. Negroes were more prone to the disease than whites. Laboratory studies revealed that 38 of these patients had bacterial pneumonia with D. pneumoniae being the most common offender; and I3 were free from bacterial invasion. Group sample studies made it almost certain that the Asian Influenza virus was a determining factor in the majority of these infections. It was also shown that pregnant patients and patients with heart or chronic lung disease appeared to be more suscep- l • ) ■ .. ■ : fj I 1 u t f, ' ■ v : . ,i;.v . i i,a v : •? •/.t i ' J » ;■ .C' :•. y; uu. ■ '‘A j. - ■ '-nv '■ ':v . j : .j i %rY:. ;;H turn* 0 m.v . w -A >•* ; D v S’ Jv taS til a . ■ ' l 1 f jr jf ■ / n' r c . i: .• ■' ■ r: * • -.j. . , :•« . • • ; ■; v:- ' • > rr.' ■ nx y ; rl.: . . ■ ‘ :i :• i ■; •• • .• .rr.' ir : 1 i- h..< .v\ it 1 v i J- • . ll \ ■■ ■ . \'. ...I • A . / ; ■ ■.s': . a•. A '1 ‘ • ■ ' 4 ' CIO! ' ic "£t■ no i v ■> .. ■ * ;r ‘,v,• * .. c- ■ ■ --• - ' 'n f '"j • •; , .V • ’ . . v .1"' , . tr ' iJ J : i ° • i V ■' , • r i; if .1 . i ■ ,»•: ... ' ••cr; .i • . / , ' 3 : ' . , ■ . / CTOjtl ttt ' r •- >: ..... : >' JJ • l ' ' ' •# i .1 ■).’ f ...' .fa. . ■ • . > n£ nX a,J- : ■' t '(I?.-■ i ■: a \ 1 r ; ; h .t • - ’ 1 ■ . ■ (i m •:.! .r tom o ■ • fl ■ ' tible to post-influenza pulmonary infections. Antimicrobial therapy with antibiotics was instituted in the majority of cases with favorable results, but a number of the group with pneumonia in which no bacterial offender could be demonstrated did well without antibiotic therapy. This suggested a viral etiology. Bloody sputum and leukopenia proved to be a poor prognostic sign. Of the 11 patients who died, k were elderly with chronic disease, but 7 were previously healthy adults. Antibiotics, adrenal cortical hormones, and supportive measures were ineffective in the fulminating course of their illness. In retrospect, the epidemic in the New Haven area resulting in 11 fatalities differed greatly in incidence and mortality from the severe wave of the 1918 epidemic, but the fulminating pneumonia described in the New Haven study in 1957 is strikingly similar to that described by Chickering and Park in an army camp in 1918,1 The conclusion drawn from the New Haven study is in agreement with Easton’s plan that the most rational approach to the problem is early prophylaxis. It was learned that this is especially true and of prime importance to pregnant women, patients with heart disease, and people with chronic pulmonary insufficiency. The epidemic left New Haven, traveled to Easton, and was over by the end of October. Some people breathed a sigh of relief, many regained their health, but a few of us realized that it would be only a matter of time until our cities would again be set upon by another seige of influ¬ enza . Chickering, N. T. and Park, J. H., Jr. Staphylococcus aureus pneumonia. J. Amer. Med. Ass., 1919, 76, 617-626. • ■ ' i . • . • . • ' ■ i - • ]■*:• 1 ‘ ' ' 1 'i-J'-U ' - .1 !" on U ' f:u :K .iv'Av U"" '1J a "o«. >■ J ' ■ '• ' v - ■ •- *' ■: • . t . • ’ v ,053*8 siJacwHvr ; n k : &cte> tfitf oqa y,£oc>1£ n . • .f" ; - > . ■ , j rf) ■ • ■ x .*• . rc. " 1 i - . ’ * r’ ' 1 • , . , /t; yr ■ . , • - V 1 7 • T ' »' V ; .J \ V i ' :0 > ,C ■ j j n! r.., Jt y •x: - 'v v .1 -j;. n2 It: •» ■ i ■ _r- ■:< i i.' .. i 'i■ • 1 : ) i -j .1.1* r rrjB v:‘id f* Ci ~i nl : >ir klfO ' * ... - X ■ ' itt W ' . ll - . B . ; io*s* > O- n ''TV ' * : ? . > ? ■ 1 '.*■ •' • •' i '»*•* 1* - ’ ' • . ad*Us , .•! , ».. ’3 . x. 26. Chapter VI Conclusion We have come a long, way in medical research and clinical applica¬ tions in the last fifty years. There remains in the forefront of our endeavors the ever elusive method or means to conquer the virus infec¬ tion. Thirty-five years ago we learned about the presence of this entity, today we must find a weapon to combat it. This endeavour will occupy the life time work of many researchers. The answer, whether it encompasses chemotherapy, preventive medicine, or both will most certainly be used to solve the ever-present problem of the influenza epidemic. I personally hope that I will be able to offer more to my patients in Easton in the future than was available to those who suffered in 1918 and 1957- (i D ; ' ' ! • ^ >V •; . :C. r: ■ i i ‘ : ' t .<)' >r. ,i j r.i ' ; ... . r ■ . .1 ► - J ^ - " !•' - 1 ■ a ' » T- ‘ ' i i j #ini : a^jtv . ■ .» ■> • >*: v, . >' , • •. '' • o J , ■ i 1 . .i j ’ -j 1 ■ . ^ . n . - ? f i .j • • I' •' f' 27. BIBLIOGRAPHY 1. Ambrus, J.L., Ambrus, C.M. and Harrison, J.W.E. Effect of anti¬ histamines on viruses of the influenza group. Amer. J- Pharm., 1951, 122, 60-62. 2. Andrewes, C.H., Laidlaw, P.P. and Smith, W. The susceptibility of mice to the viruses of human and swine influenza, lancet, 193^> 2, 859-862. 3. Andrewes, C.H., Laidlav, P.P. and Smith, W. Influenza: observations on the recovery of virus from man and on the antibody-content of human sera. Brit. J. exp. Path., 1935> 16, 566-582. 4. Bradley, W.H. Influenza. Brit. J. Tuberc., 1952, 16, 196-204. 5. Bren, Walter V., Bolling, George E. and Casper, Erwin D. Pandemic influenza and secondary pneumonia at Camp Fremont, California. J. Amer. med. Ass., 1918, 71, 2138-2144. 6. Burnet, F.M. Propagation of the virus of epidemic Influenza on the developing egg. Med■ J. Aust., 1935, 2, 687-689. 7- Burnet, F.M. Biological aspects of infectious disease. Cambridge, England, Cambridge University Press, I9I0. 31° PP- 8. Burnet, F.M. and Foley, M. The results of intranasal inoculation of modified and unmodified influenza virus strains in human volunteers. Med. J. Aust., 1910, 2, 655-659. 9. Burnet, F.M. and Clark, Ellen. Influenza. Melbourne, Australia, Macmillan and Co. Ltd., 1942. llSHpp“ 10. Burnet, F.M, The general pathology of virus infections. lancet, 1950, 1, 1059-1063. 11. Burnet, F.M. Some biological implications of studies on influenza viruses. Johns Hopk. Hosp. Bull., 1951, 88, II9-I37. 12. Chickering, H.T. and Park, J.H. Jr. Staphylococcus Aureus Pneumonia. J. Amer. med. Ass., 1919, 76, 617-626. 13. Collins, S.D., Frost, W.H., Glover, M. and Sydenstricker, E. Mortality from influenza and pneumonia in 50 large cities of the United States. Publ. Hlth. Rep. (Wash.), I93O, 45, 2277-2328. 14. Creighton, C. A history of epidemics in Britain. Cambridge, England, Cambridge University Press, 18'9'ii," "2 vops, vol. 1, 706 pp., vol. 2, 863 pp. - . >. -j . ,c i . . • I.r 1 ' aj.r/ ■ , , >.n <; >u r,c i -r ; .. r / ■/ . ■' v. ; ? / i , i r - . o : . >;j . •. rr ';:i V 1 r i f .o- •’ .in' .o ■■ ■ c ■ :n • no JL /■ . . 5 ‘ ■ fl- atii ' •! .If:' .i ; . p..? • •. ■ S' ! , . r. . i- i . si . . 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Jr. and Magill, T.P. The incidence of neutralizing antibodies for human influenza virus in the serum of human indi¬ viduals of different ages. J. exp. Med., 1936, 63, 655-668. 20. Francis, T. Jr. A new type of virus from epidemic influenza. Science, I9I0, 92, 105-108. 21. Francis, T. Jr. Plan for the evaluation of vaccination against influenza. Amer. J. publ. Hlth., 1951, ll, no. 8, 62-68. 22. Francis, T. Jr. Influenza: the news acquayntance. Ann, intern. Med., 1953, 39, 203-221. 23. Frost, W.H. Influenza - prevalence in the United States. Publ. Hlth. Pep. (Wash.), 1920, 35, 579-590. 2k. Frost, W.H. Statistics of influenza morbidity with special reference to certain factors in case incidence and case fatality. Publ. Hlth. Pep. (Wash.), 1920, 3J5, 581-598. 25. Fry, J. Lung involvement in influenza. Brit. med. J., 1951, 2, 1371-1377. 26. Gibbon, J.G. Acquired immunity in influenza. Lancet, 1919, 1, 583- 27. Gill, Clifford A. The genesis of epidemics and the natural history of disease. London, Bailliere, Tindall and Cox, 1926. 550 pp. 28. Hicks, J.A. Braxton and Gray, Elizabeth. An investigation of cases of influenza. Lancet, 1919, 1, 119-121. 29. Hirst, George K. Direct isolation of human influenza virus in chick embryos. J. Immunol., I9I2, I5, 293-302. 30. Horsfall, F.L. and Lennette, E.H. A complex vaccine effective against different strains of influenza virus. Science, I9I0, 91, I92-I9I. > - • 'L :. ,%a La . i >■ i . ■■ i - 1 ”■ 1 ■ . r;.:. , ■ • i ’ ui a r ■ / ■ • ' . • ■ •. • La_ ! i' ■ a- . . .al l » . I.. , . . . . ■'.‘it o ... j a i t . % , - o • lV . . , , ,.-.L . Yi . ... ' V : - ; ■ . i; o ai ^ : a . . : . r , i ,. ' • . Yl ■ i a ’ ' . ..' . .■ • ' rr . \ . . . t i - . . ■ ± ■ vn' a > • • •_ ,, , .. ' ■ j t u: ,1L ■ ; .'a " ‘ 1 -i ; in. . a: -i J ,n . .L ... :'0 ■ ■ . -0. , yr.yi: 1. ■ • i ' ' a ■ Wl . V y -J : A . v . , i. a .. a . 1 c:i j- .J jju . u .Aen/* . s nsw.ririj ; - ; . : ' • v . ir a - ■ L _ . r 'll ■■ ■. 1 i ■ . 'I . 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New antigenic variant in Far East influenza epidemic, 1957. Proc. Soc. exp. Biol., 19c7, 95, 609-616. 11. Opie, E.L., Blake, F.G., Small, J.C. and Rivers, T.M. Epidemic respiratory disease. St. Louis, C.V. Mosby and Co. 1921. 102 pp. 15. Pearl, R. Influenza studies. I. On certain general statistical aspects of the 1918 epidemic in American cities. Publ. Hlth. Rep. (Wash.), 1919, 3l, 1713-1783- 16. Shope, Richard E. Swine influenza. Ill, Filtration experiments and etiology. J. exp. Med., 1931, ^1_, 373-385. - . 1 . . ' .. . ,.i irst lo .. ■ . . - r I . . ■ . ,~U -. .1 ; , ,C , r. . .V ..'■■ ■' , V-J • .r; <. i . r ■ . t r. , : i ...... :j v I. ». . 1 • i . . r: > ‘" . , ... • u . •. ' - . , i ■&' - : ' \ i f . . i . ■ - . . J. ■ ■ . ) •:' ;i . !. . ) ’■ . . ’ . • ? asn . . ’ . . '• Ui: •. ui r. L., ■- f t . I. ' \n- n . J i VoK .C-> •j >.•:: #n i. \ v »- c . , ■, f j •*'. "-a i *e-> ' ,/ ?.ir /. v ’ i . ,r r • f ' . .; •>': .) :r: i t fv J:* J . 1. 1 r.J 7. M a ; ' ■ • ■ itnii". 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Influenza 1957• Philadelphia, 1957- 29 pp. no* V •'*r-'’1 > r-- b ■ ' ..Our .rf ,t o.yJ.rb • tj ' t" J:r • rrfl oJtr.iV;' .1." . > bb V':>T ’ " ?*»** '1'' - ' ' •• ‘;0 .. ■ ; ill - . :i .>;• * na .-3 v .Flvl 'to rma&UA baa ^sranwe eiii* gnlu/b ytnjk bqJbIp, badjtdO add ' ■ -• ■ : v ■;:.-; • . - V ■ 3 • - •3 ! ■ 1 - . i . i . Oil , i* do -!"• cn in 'Pi . . W - . . . ' - Cffl f i : o 'tv , ■.o'. , . j .. ■ . • T'^-T , elifci* u-.;i: [ n 2-' l . sejtioJ"modal t ft>xw YALE MEDICAL LIBRARY Manuscript Theses Unpublished theses submitted for the Master's and Doctor's degrees and deposited in the Yale Medical Library are to be used only with due regard to the rights of the authors. Bibliographical references may be noted, but passages must not be copied without permission of the authors, and without proper credit being given in subsequent written or published work. This thesis by has been used by the following persons, whose signatures attest their acceptance of the above restrictions. 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