One of the most remarkable things about the 1918 pandemic was the great rapidity with which it spread to all parts of the world. From the report of the first cases which landed in Boston until the epidemic arrived in San Francisco the time consumed was less than two months, and the peaks of the two epidemics were just about one month apart. Apparently no part of the world escaped. Asia, Europe, Africa, North and South America, and some of the remote islands of the Pacific, all reported large epidemics, with high mortality and great suffering. The deplorable failure of precautionary measures in controlling the spread, or at least in limiting the disease, may be offset in a measure by the unusual conditions under which almost everybody had been living. Vast numbers from all over the world were gathered together because of the war. Thousands of men were housed together in army camps or in training cantonments. Other thousands were doing relief work or engaged in the manufacture of munitions. Most of those at home were doing double duty, and were on a severe nervous strain. Everyone everywhere was working to the limit and was consequently fatigued. The necessities of war had cut down the amounts of food generally, and sugar and fat rations particularly. Traffic, both between nations and at home, had never been so great nor accommodations so insufficient. So that it is likely that all of these and many more changes in the daily routine of individuals led to a condition of lowered resistance, and at the same time increased their chances of exposure. One point, at least, stands out prominently, and that is that “influenza as it occurred clinically during the first great wave was different from those cases which appeared later.” This was seen in the acuteness of the onset, in the severity of symptoms, and in the high mortality rate. Therefore, any measure which afforded protection, if only for the time being, is worthy of retrial.
In view of the fact that recurrences have followed closely in the wake of all former influenza epidemics, and with the hope of stimulating concerted investigation of preventive measures, the American Public Health Association (57), at its meeting in Chicago in December, 1918, appointed a committee to outline “a provisional working formula, based on the facts and opinions brought out at the meeting.” A summary of the opinions as taken from the report of the committee is given here. They reported that the disease was probably due to some micro-organism or virus as not yet identified; that while it was known as “influenza,” it was not known to be identical with the disease generally known under that name; that there was no known laboratory method of differentiating it from ordinary colds, bronchitis, etc.; that there was no known laboratory method of determining when a patient ceased to be infective; and that the deaths from influenza were due to secondary pneumonia resulting from an invasion by one or more forms of streptococci, or by one or more forms of pneumococci, or by the so-called influenza bacillus or bacillus of Pfeiffer. Because of the clear and concise manner in which this report brings out the opinions held, at the time, by a majority of the medical profession a portion of the report is given here verbatim.
“Evidence seems conclusive that the infective micro-organisms or virus of influenza is given off from the noses and mouths of infected persons. It seems equally conclusive that it is taken in through the mouth or nose of the person who contracts the disease, and in no other way except as a bare possibility through the eyes by way of the conjunctivæ or tear ducts.
“If it be admitted that influenza is spread solely through discharges from the nose and throats of infected persons, finding their way into the noses and throats of other persons susceptible to the disease, then, no matter what the causative organism or virus may ultimately be determined to be, preventive action logically follows the principles named below, and, therefore, it is not necessary to wait for the discovery of the specific micro-organism or virus before taking such action.
“1. Break the channels of communication by which the infective agent passes from one person to another.
“2. Render persons exposed to infection immune, or at least more resistant, by the use of vaccines.
“3. Increase the natural resistance of persons exposed to the disease by augmented healthfulness.”
The ways and means of carrying out these principles are many and varied, and it is merely the intention of this paper to put together a sort of digest of some of the more important arguments for and against some of the seemingly more important measures proposed.
Methods Proposed for Breaking the Channels of Communication
(a) Rigid quarantine for all persons suffering from the disease and all contacts. During the epidemic quarantine was advocated by many people. It was pointed out that the disease spread most rapidly in camps, in ships, and in quarters generally where large numbers of persons were closely associated; that it was quite as contagious and more rapidly fatal than most diseases which are regularly quarantined; that while it was admitted that there is no laboratory method to make certain the diagnosis, and no method of telling how long convalescents are capable of transmitting the disease, as there is, for instance, in diphtheria, still there is no question of the value of the arbitrary quarantine used in measles, scarlet fever and smallpox, all of which are diseases in which the parasitic causes are not known. Further, the opinion was expressed that complete isolation and quarantine would not only protect the community from influenza, but that it would also in a measure protect the patient from contact with numerous outside strains of pneumococci and streptococci, and so lessen secondary infection and reduce the general mortality.