Studies on Epidemic Influenza: Comprising Clinical and Laboratory Investigations

by University of Pittsburgh. School of Medicine

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.

One of the best descriptions of that epidemic was given by Dr. O. Leichtenstern in Nothnagel’s Encyclopedia of Practical Medicine. This contribution, among many others, describing the epidemic of 1889 and 1890 is one of the first to refer to the Pfeiffer bacillus as being etiologically associated with the disease. It differs, therefore, greatly from descriptions of previous epidemics. Leichtenstern says: “The typical influenza consists of a sudden pyrexia of from one to several days duration, commencing with a rigor, and accompanied by severe headache, generally frontal, with the pains in the back and limbs, by prostration quite out of proportion to other symptoms and marked loss of appetite.” He continues by saying that to these characteristic symptoms may be added the catarrhal phenomena arising from the affection of the respiratory tract, particularly the upper (coryza) and “occasionally” the lower, the trachea and bronchi. This description is so in accord with the symptoms of uncomplicated influenza as found in the present epidemic that very little need be added. Any difference which may occur in the description of the disease is likely to be accounted for by the peculiarity of onset, whether in the upper or lower respiratory tract, and by the different ways of interpreting complications which may have arisen. It is evident from this description that the upper respiratory tract was affected more generally than the lower in the epidemic of 1889 and 1890. In the present epidemic it can safely be said that the reverse was the usual state of affairs. It was a rather unusual occurrence when the affection was limited only to the nose, pharynx, larynx, trachea and larger bronchi. A very large number, no doubt, had a peculiar œdema, a so-called “wet lung,” which we shall discuss later; others went on to a capillary bronchitis or a bronchiolitis, and a large number had broncho-pneumonia. This sequence we shall attempt to show in the statistics at hand. In some cases the lesion in the lower respiratory tract seemed to be primary, there having been no initial coryza. At least none was observed and no history was obtained.

Prodromal Stage and Communicability

The length of the prodromal stage—the stage from the time of contact to the earliest onset of symptoms—has always led to interesting observations and discussion. In this epidemic we have rather definite information bearing upon this subject.

A young married farmer living in a rural community where no influenza had occurred up to the time of the present experience went to a city about 40 miles distant. On the train he sat in the same seat with a man who was apparently ill, and who was sneezing and coughing. He was in the city only a few hours, and was not in any place of congregation except the railway train. Forty-eight hours after his return to his home he noticed the first symptoms and began a mild course of influenza. About 50 hours later his wife was taken with the same symptoms, and in two days more their only child was afflicted. Other members of the household were also afflicted, and one of them died of pneumonia.

It might be interesting to quote a similar observation made by Macdonald and Lyth, of York, England, published in a recent issue of the British Medical Journal (November 2, 1918, p. 488), which corroborates this experience. They say: “We traveled from London together on Thursday, October 3, by train, leaving King’s Cross at 5.30 P. M., arriving in York at 9.30, and as we were leaving the carriage a young flying officer, who had come the whole way with us and was coughing and sneezing at intervals, informed us that he was ill and had had influenza for several days. On Saturday, October 5, we both became ill and had developed typical attacks of influenza. With both of us the illness developed suddenly with laryngitis; in both the first signs were a severe attack of coughing; and in both the time was noted fairly accurately as being between 2 and 2.30 P. M. One case was quite mild, the temperature never over 101. The other was more severe; the temperature arose to 104½ and the catarrh extended to the bronchi. His wife and two children also developed influenza, and in their case the symptoms showed suddenly, about 2 P. M., on Monday, October 7. Now we are convinced that we became infected from our traveling companion during the train journey—more likely toward the end of the journey; and if we take the time of infection as 9.30, this fixes the incubation period for both of us at a minimum of 41 hours, with a maximum margin of error of 4 hours. The three cases developing in the family of one of us point to a similar incubation period, as their illness started almost exactly 48 hours after his, and as it is likely that the infection would not take place until a few hours after the first symptom, the incubation period in these three cases must have been nearly the same as our own two.

“It can be readily understood that we were in no position to conduct extensive bacteriological examinations, but a culture taken from the posterior nares of one of us on October 10 with a guarded swab showed colonies of Pfeiffer’s bacillus and of micrococcus catarrhalis.”

This observation is so convincing, I have quoted it at length and in full.