Influenza

by Warren T. Vaughan

Those who seek to find in a study of the epidemiology of epidemic influenza the secret of the causation of the disease, and its ultimate eradication, are probably predestined to at least partial failure. We must call upon the bacteriologist for information as to the causative organism, and in time he may be able to furnish us with satisfactory prophylactic measures, particularly with a successful vaccine.

But while pure epidemiologic studies will not demonstrate the ultimate factor in the etiology, nevertheless these studies do subserve several most important functions. The bacteriologist, the immunologist, the serologist have accumulated a wealth of information since the 1918 pandemic, but as far as definite conclusions concerning the causative agent of the disease are concerned we are no nearer to the truth than we were at the time when Pfeiffer made his original observations. There is no incontrovertible evidence by which one may say that the influenza bacillus is or is not the cause of the disease. We must therefore await further studies and future discoveries. But we cannot await idly in the knowledge that new epidemics of the dread disease will surely come, probably mild ones in the next few years, and certainly severe ones again within a few decades. We must amass all of the available information concerning the mode of action of the disease, its manner of spread, its degree of infectivity, its distribution and the mode of its recurrences, and try to formulate from a study of the available facts some means of protecting ourselves against the epidemic, if not of preventing it entirely.

In short, in the present state of the bacteriologic knowledge of the disease, we may say that the epidemiologic features are the only facts upon which we have to build in planning our defense. Today, the practical work in the eradication of influenza must depend chiefly, if not solely, on the general methods of preventive medicine.

Many valuable monographs have been written on the subject, particularly following the pandemic of 1889–1893, but these have all emphasized features and phases of the disease which seemed at that time to be particularly important. Facts which seemed of extreme importance to the earlier writers are today in some instances considered relatively unimportant, while other phenomena which were but touched upon by the former investigators today have assumed deep significance. For this reason it is worth while to reproduce here the observations made in previous epidemics, and to correlate them with the facts developed in the abundant literature of the last few years, and to draw therefrom inferences as to the life and habits of the influenza virus, and conclusions as to the means of interrupting its progress.

Historical.

The history of influenza can justly be divided into two phases, the first ancient, and the second modern. The latter period begins with the 1889 pandemic. By that time the science of bacteriology had altered our concepts of the etiology of disease and epidemiologists had begun to avail themselves of statistical methods of analysis. For the purposes of this paper, therefore, consideration will be given chiefly to the epidemic of 1889, and a summary of earlier epidemics will be made merely to refresh our minds concerning the antiquity of the disease and the periods of its occurrence. References to the earlier epidemics will be made more particularly in the special discussions later, where points of similarity or difference will be brought out. Further than that it is unnecessary to go in the history of the disease, for the several excellent monographs of 1890 to 1900 tell the historical story in a manner that could scarcely be improved upon.

The great antiquity of epidemic influenza is a fact which I think may be admitted in spite of some who hesitate to accept it because of lack of convincing descriptive evidence. Some believe that the epidemic of the year 412 B.C., described by Hippocrates and by Livy, was an epidemic of influenza. Some have suggested that the epidemic described by Thucydides was the same disease. Parkes remarks that the epidemic pervading the Athenian Army in Sicily in 415 B.C., recorded by Diodorus Siculus, has been supposed to have been influenza. Finkler, in referring to a report by Diodorus of a pestilence occurring in 395 B.C., which broke out in the Greek Army at the siege of Syracuse, and which killed off the soldiers murderously, says that this could not have been influenza. He regards as sufficient argument the fact that the mortality was high. After the epidemic of 1918, one is more inclined to believe that the epidemic in Sicily may well have been true influenza. We must remember that previous to the last few pandemics the stories have been fragmentary in character and were told, not by physicians, but chiefly by the historians of the time, men who have desired to impress their readers with some idea of the horrible ravages of the disease, and who have doubtless in some instances transmitted the impression of monstrous mortality rates. The early historians were much given to figures of speech, many of which were very telling in conveying the impression desired. Finally, the writers of the middle ages and of earlier times had little or no statistical material on which to base their conclusions. I have no doubt that a historian who during the 1918 epidemic of influenza might have limited his observations entirely to the disease as it occurred at Camp Sherman, Ohio, and who saw 125 robust soldiers dying each day, would have truly written that the disease killed off the soldiers murderously. A further statistical argument in favor of considering the epidemic among the Greek soldiers as quite possibly influenza is the fact that as shown by present day findings these men were all of the age in which the mortality is highest, and were living under sanitary conditions which predispose to high incidence and high mortality.

According to Parkes, in 827 A.D., an attack of “cough” which spread like the plague was recorded. In 876, Italy and later the whole of Europe was attacked, and the army of Charlemagne, returning from Italy, suffered greatly. “Dogs and birds were attacked at this time.” In 976 the whole of France and Germany was attacked by a fever whose principal symptom was cough. There is also record of diseases which may have been influenza which were seen in Germany and France in 927 and in England in 996 and 997. All of these records are indefinite and from their nature unconvincing to a critical student. Several investigators have gone over these past records up to 1889 with the idea of determining definitely what plagues were, and which were not, true influenza. The criteria used by the various investigators have differed slightly in some instances. For instance, one chooses to use the record of low mortality in widespread epidemics as the chief characteristic of pandemic influenza, while another emphasizes principally the complications.

The experience of recent years has amply demonstrated that influenza may be characterized by a high mortality or a low mortality; that pneumonia may be prevalent or relatively rare during an epidemic. These features are not truly characteristic of influenza itself. They are phenomena which depend chiefly for their existence on secondary invasion with organisms other than the causative agent of influenza. It may be that the influenza virus itself is capable of producing pneumonia, but it is generally accepted that an overwhelming majority of the complicating pneumonias are due to secondary infections. One perusing the former literature today would hesitate to state that an ancient epidemic was not influenza merely because it was accompanied by high mortality, nor would he wish to say that it was not this disease because there was no mention of a high incidence of pneumonia. We have had both types within the last few years, as in March and April, 1918, when the disease appears to have been accompanied by a very low mortality and a low incidence of pneumonia, and in October of the same year when the pneumonia incidence and the death rate were both relatively much higher.

Attention should be called to a certain inaccuracy which has appeared in the literature and which has resulted in some instances in a misunderstanding of the entire history of influenza. Finkler says: “According to August Hirsch the first influenza epidemic occurred in 1173 and he places it in his work as the first out of eighty.” This has given the impression to some that influenza was unknown previous to that date. Leichtenstern has quoted Hirsch more accurately and thereby given an entirely different meaning to the statement. “August Hirsch says that the first epidemic that can be definitely said to be influenza occurred in 1173.” Jordan also conveys the latter impression. He remarks that the first extensive, well described epidemic of influenza occurred in 1510.