Studies on Epidemic Influenza: Comprising Clinical and Laboratory Investigations

by University of Pittsburgh. School of Medicine

Oskar Klotz.

Pittsburgh, June, 1919.

HISTORY AND EPIDEMIOLOGY OF INFLUENZA

By James I. Johnston, M. D.

The history of epidemic influenza extends back with definite authenticity to the Middle Ages, with a fair amount of assurance to the beginning of the Christian Era and with presumptive reliability even before that period. Beyond this statement, nothing definite can be said until the first epidemic reported by Short and found in the English Annals in the year 1510. This, the first reliable record, presented some features not unlike those occurring in the present epidemic. Two or three striking things stand out in this record—namely, the presence of nose bleed, pneumonia and the very great danger to gravid women. Here, for the first time, the meteorological conditions were elaborately studied and persistently dwelt upon. One other impressive thing, also reported by Short, was that in 1580 the disease showed a tendency to return after a period of quiescence. Attention is called to this because the epidemic, while it was exceedingly prevalent in the months of August and September, became pandemic in October and November. Another feature was that during the years intervening between 1580 and 1658 sporadic cases of this disease were frequently reported. During the latter year another epidemic appeared in the month of April. In 1657 and 1658 at London the summer was very warm, the winter came on early, there was much snow and the spring was very moist.

The prevailing opinion at this time, and the first stated by Willis, was that the widespread disease was due to the weather influences on the circulation, poisoning the blood of the patients, and “not blasts of malignant air.” The disease prevailed in the large cities, recurring again in the autumn in an extensive form through the villages and country. Sydenham, in his communication on the epidemic in 1675, wrote emphatically on the influence of the infection on pregnant women, and here used the term “tussis epidemicus” as a name for the disease. The summer of 1675 was wet with an inconstant autumn. La Grippe prevailed in France and Germany, according to Atmuller. In England in 1676, the autumn was pleasant, but suddenly became cold and moist. La Grippe then started in Germany during September after a summer and a beginning autumn which was very rainy. Molyneux in his description of the epidemic of 1693 in Dublin called attention to a feature, very striking to the recent pandemic, that the aged to a great extent escaped the infection. This would seem a somewhat unique feature until that epidemic is compared with the present one. In 1729 Morgagni and others stated that over all Europe the winter of 1728 was very rigorous, the spring was cold and the summer and autumn very variable, while January and February of that year were very moist. Huxham in his record of 1729, the fifth extensive one on record in the English Annals, which extended into 1733, stated from his study at Plymouth that the epidemic was exceedingly mild in the year 1733, and, with the exception of infants and consumptive old people, the mortality was very low. Like many of his predecessors, he emphasized greatly the conditions of the weather at the time and presented an elaborate study of it. The epidemic of 1732 was one of the longest and most persistent, extending up to 1737. All authors do not hesitate to attribute as a cause the very frequent variations of temperature which characterized this period. Of this epidemic Arbuthnot also emphasized the importance of the air, assigning the prevalence and widespread features of the disease to the thick and frequent fogs. From November, 1732, until March, 1733, this disease spread from Germany to Italy and thence to England. He called attention to a very striking feature—namely, that people in prisons and in hospitals escaped the disease. This, as we know, where such institutions are placed under preventive quarantine, is not such a unique feature during this present scourge. He, more than former writers, devoted pages to the elaborate and accurate description of instruments for meteorological observation and their findings, which meteorological records were published in detail, covering the whole period of a year—June, 1732, to June, 1733—with almost daily regularity. Huxham in 1737 in his record first used the term “epidemic catarrhal fever”—a name often used subsequently to describe this disease. Here attention was first called to the prostration which characterized the convalescents, and his belief that consumption frequently followed the disease. The next epidemic, which occurred in 1742 and 1743, was also reported by Huxham, who stated that the weather was very rigorous. This disease, according to his description, extended over all Europe, and the term “influenza” seems to have been first used by him during this time. The cases were mild in England, but more severe in Southern Europe. Whytt in his record of the epidemic of 1758 was the first who did not consider that the air condition or the seasons had the significance attributed to them by former writers, since the weather conditions during the prevalence of the disease were generally mild and dry. In Edinburgh at this time not even one out of seven escaped. Nevertheless, he did not hesitate to express his opinion that the disease did not spread by contagion from one person to another. One other observation of his is worthy of note, which is: that frequent relapses occurred when patients were re-exposed too soon after the first infection and such relapses were much more severe than the original disease.

The epidemic of 1762 called forth the opinion of Baker, emphasizing an opinion already expressed by Whytt, that the origin of epidemic disease is not due to changeable winds nor to their nature or character as recorded by the barometer. This epidemic also prevailed over all Europe and appears to have begun following sharp alterations of cold and moisture. In 1766 in Spain, France and other parts of Europe the epidemic appears to have begun after a warm summer, followed by an autumn moist and cold. In 1767 Heberden placed on record his observations during this period, but nothing new was reported. In 1775 the disease began in Germany in the summer after a dry and warm spring and spread over all Europe. During the prevalence of the disease in 1775 a questionnaire was sent to the leading English physicians, and letters from Fothergill, Sir John Pringle, Heberden, Reynolds and others seemed to express a consensus of opinion that weather conditions had nothing to do with the prevalence or spread of the disease, and that the cause and reason for its spread were unknown. Following sharp alterations in temperature in 1780, the disease appeared in France and then throughout the world. The epidemic of 1782 began in Russia, starting January 2 at St. Petersburg. The thermometer underwent a variation of 40 degrees and the same day 4,000 were afflicted with La Grippe. It reached Koenigsburg in March, Copenhagen in April, London in May, France in June and July, Italy in July and August, Spain and Portugal in August and September, and then reached America. Edward Gray, writing of the epidemic of 1782 for the first time, expressed emphatically his opinion on the contagiousness of the disease and stated what we now know—that close contact is necessary. To him also is attributed the opinion first mentioned by him, that there is a possibility of carriers in this disease. During this time Dr. Hamilton, in a published letter, protested against venesection in influenza, a practice long prevalent, and Hogarth called attention to the fact that the disease began in cities and villages first and that it was brought to these places by visitors from without.

The first American writer on this subject was Noah Webster in 1647 and 1655. Following him was Warren, writing of the epidemic of 1789 and 1790, just 100 years before the last and greatest epidemic which preceded the present one. Rush and Drake also reported this epidemic. During that epidemic which prevailed in America from September to December, 1789, and appeared again in the spring of 1790, President Washington suffered a very severe attack. The year before, in 1788, when the epidemic prevailed abroad, the summer temperature in Paris was very variable, variations of 8, 10 and 12 degrees occurring on various days. La Grippe predominated all the time. The same variations were true in Vienna. At the end of the year 1799 the epidemic struck Russia, following very cloudy, misty weather, was prevalent in Lithuania in January of the year 1800 and in Poland during February.

The next great epidemic occurred in 1802 and 1803, was very general, beginning in France and coinciding with a cold and moist autumn following a very dry summer. It was of six months’ duration in England. Many schools, jails, asylums and workhouses, although located in the area swept by this plague, at first escaped. As mentioned before, this striking feature has not been so unique in subsequent epidemics. One feature noticed here and commented upon freely was that elsewhere throughout the country there seemed to arise endemic foci. During this time there was also the prevailing belief that the disease was followed by phthisis. One other observation made here, which was accurate, lasting and is accepted today, was that no family was affected en masse, but always one individual case occurred first, to be followed by general infection of the others. At this time early bleeding was still adhered to. The French spoke of seven varieties of the disease, but one can only see in the classification emphasis laid on certain individual symptoms in this disease of complex symptomatology. During this epidemic pneumonia is said to have been very infrequent. The disease was particularly fatal to pregnant women, and the patients suffering from pulmonary tuberculosis were hurried off by the influenza.

Burns, writing of the epidemic of 1831, mentioned that in 1810 the disease was very widespread in China and Manila, and also emphasized the fact mentioned in many works that certain epidemics prevailed among animals at the same time, stating that in 1831 these diseases were of choleric nature. This epidemic began in 1830 in the East, reached Paris in the summer of 1831, reappeared in Europe in 1833, following the same route that cholera had taken in 1832. In the epidemic of 1833, Hingeston also laid great stress on the fact that horses were often affected. These features, as mentioned by Burns and Hingeston, are frequently quoted by authors, and such observations seem to have been widely accepted.