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The Spanish Influenza - 1919

Demonstration at the Red Cross Emergency Ambulance Station in Washington, D.C.

Demonstration at the Red Cross Emergency Ambulance Station in Washington, D.C., During the Influenza Pandemic of 1918. National Photo Company Collection at the Library of Congress. LC # 2016844534. GGA Image ID # 1504ad78c2

The Black Plague Of 1918, The Worst Pandemic Disease That Has Scourged the Civilized World in Four Centuries

By Leonard Keene Hirshberg, M.D.

In the early days of the year 1918 we began to hear rumors of the appearance of a new and virulent plague in Europe. The collapse of Russia had released large German forces on the eastern front, and the war lords of Berlin had openly boasted that with these additional troops they intended to crush France and England before America could come to the aid of her sorely tried Allies.

But the weeks passed, and the threatened final assault upon the freedom of the world was unaccountably delayed. January and February went by, and still the " sharp German sword," of which the former Kaiser used to be so fond of talking, did not spring from its scabbard.

It began to be whispered that a new plague, the first pandemic scourge of the present world war, had made such inroads upon the German military machine, as well as upon the " home front " behind, that the western offensive had to be postponed until the worst of it was over. The end of the third week in March saw this point reached, and the onslaught began.

For want of a more accurate name this modern plague, the like of which has not been experienced by humanity in four hundred years, has commonly been called Spanish influenza.

Yet it did not originate in Spain, nor was it exactly the grippe or influenza of other days. It appears that the Germans, in anticipation that the malady might be justly named German plague, sent broadcast a misleading name which they had craftily devised before the infection spread from Germany to other countries.

Bacilli are the cause of influenza, as they are the cause of bubonic plague, the old " black death " of fourteenth-century England, and still a dreaded scourge of mankind. The specific bacilli of both these contagions were discovered by a Japanese physician and bacteriologist, Kitasato.

The name of Dr. Pfeiffer, a German, has commonly been attached to the discovery of the influenza bacillus, as a result of the well-known Teutonic methods of advertising their scientific men and decrying or ignoring those of other countries.

The records show that Professor Kitasato announced his identification of the bacillus early in January 1892, while Pfeiffer made a similar announcement at the end of that same month. English and American physicians mistakenly accepted the German version of the matter and called the influenza virus the "Pfeiffer bacillus."

Dr. Kitasato, one of the world's greatest bacteriologists, the discoverer of many bacteria notably the plague bacillus, which he first identified in Hong-Kong in 1894—has too long been unjustly deprived of credit for his work.

War has always been a breeder of pestilence. It is estimated that the bubonic plague alone has taken no less than two billion human lives. In addition, outbreaks of smallpox, cholera, typhus, and yellow fever have followed debilitating wars.

Fortunately our enormous progress in medical knowledge, and our increased resources for combating disease, give assurance that no plague epidemic of such magnitude as those of the past can occur in America at the present time.

The first known advent of the new form of influenza to this country occurred when the Norwegian ship Bergensfjord arrived at New York on August 12, 1918, with twenty-five cases, three of which proved fatal, but there were probably other sources of infection, even if we dismiss the report that the German U-boats surreptitiously disseminated the contagion here.

It was apparently by some other line of attack that the disease reached Boston and New England, where it raged most alarmingly for a time, especially among the soldiers in training at Camp Devens. The total number of cases at the camp exceeded nine thousand, and there were as many as seventy deaths in a single day.

The Symptoms of Spanish Influenza

From observation of one thousand soldiers it was found that from one to three days after contact or approach to others who had the disease a feverish state began.

The fever rose steadily until, on the second or third day afterward, it was as high as occurs in pneumonia. In many cases the patient's temperature went as high as one hundred and four degrees. Pneumonia, indeed, is one of the commonest and most dangerous complications.

The disease starts with a chill, or chills, which may shake the room. Severe headaches are generally present, with pains in the legs, in the groin, in the neck, in the spine, and in the small of the back.

Then "that tired feeling," named by doctors " general malaise," takes charge of the sufferer's anatomy. The victim feels wretched all over. The face is flushed. Fever blisters — a frequent accompaniment of pneumonia, meningitis, and tertian malaria—break out on the sufferer's lips.

Spanish influenza runs its course with Liberty-motor speed, reaching its crisis on or about the second day. On the fourth day, as a rule, the patient is well, or else pneumonia or some other complication has asserted its dangerous presence.

A harsh cough is a frequently encountered symptom. The patient hacks and sprays forth great numbers of the microbes, which spread the infection rapidly unless handled with the greatest precaution.

A thick, tenacious sputum of a whitish mucoid character differentiates the new disease from the old form of influenza with its greenish sputum. This feature also distinguishes Spanish influenza from pneumonia, with its typical rusty-colored expectoration.

A failure of intestinal action, a restricted flow of the kidney fluids, and a want of appetite are also among the characteristic signs and symptoms.

If you take close notice of the several differences between the new malady and the old influenza, you will observe that the fever is sharper and higher, but of shorter duration; the total course of the new scourge is briefer; there are fewer stomachic or intestinal symptoms in the Spanish influenza, whereas in the old form of the disease gastro-intestinal disturbances were predominant.

But the final proof of the fact that the new influenza is a distinct malady is afforded by the identification of the specific microbe which causes it. This interesting discovery was due to the researches of three army surgeons, Captains T. R. Little, C. J. Garafalo, and P. A. Williams, of the Canadian Mobile Bacteriological Laboratory, attached to the British base hospitals.

The Germ of The Plague

The new bacillus is not found in the blood, and cultivation of it in that medium is impossible. It is lucky that so demoniacal a germ does not penetrate the delicate fluid tissue of man. If it did so, its malignancy might easily be tenfold greater.

The bacteriologists discovered it by exploring the discharges and excretions from the nose, the pharynx, and the throat of influenza patients.

Here, spread upon glass, and examined under a magnification of twelve hundred times, a new world of microscopic organisms opened up before their gaze.

They saw a veritable beehive of trembling, vibrating bacilli, almost as round and small as the diplococcus of meningitis — a diplococcus being a type of microbe in which two dot like or disk like shapes are attached to each other. At the poles, or opposite ends, these tiny germs had blunt noses, flattened out so as to make them almost biscuit-shaped.

In no "smears" of these bacteria were there any of the well-known Pfeiffer or Kitasato bacilli of influenza, or any double cocci of pneumonia. The newly discovered germ has characteristics peculiarly its own, which were described in the London Lancet and the British Medical Journal in July and August 1918.

As a rule the microscope reveals so many bacteria superficially alike that a mere examination of them, undyed or unstained, without planting them in various small test tubes of different soils, would mislead even an expert into believing them identical.

For this reason bacteriologists must use a great many other tests to convince themselves—not to mention their skeptical confreres and critics—that they have a new and a different germ.

When they find and isolate a bacterium under the microscope, and it resembles—even when stained blue or otherwise—the diplococci of pneumonia or meningitis, they "put iodine on its tail," as it were. The result of this test decides whether it belongs to the group of organisms that " take" iodine or to those that do not do so.

Then it is planted in gelatin. It either grows and melts the gelatin, or it does not. Thus another differentiation is found.

Then potato, sugar, banana, bloodserum, and other "soils" are used until a whole series of facts are found, either identifying the bacterium with some previously known species or proving it different from anything hitherto catalogued.

Thus it was with the new germ. The medical gentlemen determined that it possesses characteristics which distinguish it from any bacillus ever "brought into captivity."

It grows with extreme reluctance upon the various media on which most other micro-organisms thrive. It thrives and grows best on blood-serum media, although it has never been found to inhabit the human blood.

There is a luxuriant and abundant sprouting of the malicious bacillus in this serum soil—which explains why Spanish influenza clings so tenaciously to the lips, the tongue, the mouth, and the gums of its victims and its carriers.

The physicians and scientists of the Allied countries have seriously considered whether the germs of the disease were intentionally disseminated by the Kaiser's government, with the intention of weakening Germany's opponents.

No definite conclusion has been reached on this point, but the suggestion cannot be hastily dismissed, as the German war lords stand officially charged with sending disease-germs to their embassy in Rumania.

Documents published by our State Department have told how bottles containing cultivations of the microbes of anthrax and glanders, bearing a German consular seal, with directions for their use in spreading infection, were found secreted in the German legation at Bucharest, after the American envoy took charge of the place.

The Terrors of The Plague

The present plague is probably the most malignant pandemic that the world has experienced since medieval times, when Boccaccio's ladies and gentlemen had to run away from Florence to escape an outbreak of the bubonic plague.

In one of our army cantonments I saw more cases of pneumonia at one time than have entered the Johns Hopkins Hospital in the thirty-odd years of its foundation.

In civil, as in military life, pneumonia was far and away the most frequent complication; and this led to the revival of the old name of " black plague " for the new disease, the bodies of many of its victims being cyanotic, or purplish-black in color, at the approach of death.

Another similarity between Spanish influenza and the bubonic plague was the number of rats and other rodents found dead. One day last October I noticed, and reported to the United States Public Health Service, three dead rats lying within a few blocks on three of the most prominent streets in Baltimore. Rats and their fleas seem to be the spreaders of contagion in several epidemic diseases.

The lands of southern and southeastern Asia are never wholly free from endemic plagues. Sir William Osier is authority for the statement that the Manchurian outbreak of pneumonia plague in the winter of 1910-1911 was one of the most virulent on record, carrying off more than four thousand five hundred persons in a few months.

What will Sir William have to say of the present epidemic, which, in New York alone, carried off more victims than that in a few weeks? Even in the much smaller city of Baltimore as many as a thousand a week succumbed.

The Fight Against Influenza

When a destructive plague sweeps over the world, we are asked by many in dividuals: "Will a cold spell check the disease?" or " Will warm weather stop the epidemic?"

While no complete answer can be truthfully given to these questions, it may be answered that neither hot spells nor cold spells have any important influence upon bacteria.

Only when the whole population has protected itself thoroughly, or when it has passed through the epidemic and has been found immune, or has been made immune, will the disease die down.

Immunity from a prevalent scourge may depend on several things. Some are lucky enough to receive no bacilli. Others get only a very few, or dead or weakened ones, and thus never know that their blood received from nature a vaccine which made it produce a large quantity of protective antitoxin of its own manufacture.

A wise preventive measure was passed by the city council of San Francisco, making it compulsory to wear masks of sterilized gauze. The nose, eyes, and mouth are the grand entrances of the human form divine.

If they are closed to the admission of dust and dirt, many distempers are shut out of the human corporate limits.

One great method of fighting epidemics is by the use of vaccines, like those that have proved successful against typhoid and smallpox. Vaccines or antiserums, however, do their best work against an ailment —such as typhoid, smallpox, or yellow fever—which attacks a patient only once, and thereafter leaves him immune for life.

Colds, pneumonia, and the older form of influenza are not visitations of that kind. They do not immunize their victim but leave him over susceptible to a fresh attack. Evidently, to inject their germs, or serum, would be likely to work havoc and not to ward off or cure the trouble.

With plague, cholera, and the present disease, however, immunologists have happily found that the bacteria involved, when killed and bottled, can be used as material to inoculate into healthy persons to protect themselves from the affection. In fighting influenza such serums have already been tried with good results.

Results of Recent Research

Men of the United States Public Health Service, as well as the bacteriologists of the army, have made many new researches during the present epidemic. They have established laboratories for the production of vaccines made of the bacteria which are found associated with influenza and pneumonia.

Doctors and nurses offered themselves freely to be inoculated or vaccinated with these killed bacteria, and many were thus saved from the disease.

In the various complications of the present plague—whether you call it by one name or another, it is equally malodorous—at least eight different species of bacteria have been captured, identified, labeled, cultivated, tried, judged, and found guilty.

These include four different pneumococci, types of pneumonia germs: Kitasato's influenza bacillus, Kitasato's plague bacillus, the streptococcus hemolyticus, and the streptococcus viridans.

Experience is full of unremembered errors, and human judgment constantly fails to take into account the altered circumstances and varied conditions of almost every individual case.

Pneumonia, for instance, to the average layman, means one thing; to a careful observant and well-informed physician it may mean any one of several things, each completely different from the others.

Not to speak of the individual variations of particular cases, there are at least twelve different types of pneumonia. There are four types of the pneumococcus, the most common bacterium of pneumonia.

There are four other species of bacteria—the bacillus of influenza, that of bronchopneumonia, and two species of streptococcus—which may cause pneumonia. There are also four less common pneumonias, the typhoid, tuberculous, plague, and injury pneumonia.

The instant a correct diagnosis has been made, and one or more lobes or bronchioles of the lung have been discovered to be solid and congested, some blood must be drawn from the arm veins and planted in gelatin, or other bacterial soil, to cultivate and identify the bacilli contained in it.

If the guilty microbe proves to be what is known as Type No. i of the pneumococcus family, you are fortunate, because there is an antitoxic serum successfully in use against it.

The treatment of the other eleven varieties of pneumonia calls for a vigilant nurse and an attentive doctor who knows when to employ and when not to employ digitalis, codeine, water, and other medicines.

Lieutenant H. M. Thomas, of Camp Meade, and Lieutenant Brumbaugh, of the same base hospital, have found that the Rockefeller-Cole anti-pneumonia serum is harmless and can be employed while waiting the results of the bacterial tests. No harm is done, even if the pneumococcus found is not Type No. 1. The earlier the serum is used the surer its success.

About ninety-five per cent of Type No. 1 pneumonias then recover. There is less success in the treatment of the other pneumonias. At Camp Meade only 87.5 per cent of all types recovered; and as about one-third of the cases were of the first type, this shows a percentage of about eighty for the other forms of the disease.

Strange to say, and contrary to the experience of the Johns Hopkins Hospital, the colored troops, while more liable to pneumonia than the white troops, had a death-rate only two-thirds as great.

The Type No. 1 pneumococcus often mingles with the bacilli of influenza pneumonias. The antiserum used upon such cases at Camp Devens, in Massachusetts, by Captain J. H. Wyman, diminished the deaths considerably, bringing them down to seven percent.

It is better to treat these pneumonras with a small quantity of strong serum ready-made from horses that have been vaccinated with Type No. 1 pneumococci, obtainable through the Rockefeller Institute, than to use large quantities of a low-grade serum.

Lieutenant-Commander L. W. McGuire, of the navy, has gone another step forward in the treatment of influenza pneumonia.

At the Chelsea camp hospital, on September 28 last, he and his assistants began to use a scrum taken from the blood of convalescent patients. Up to the time of his report, twenty-seven patients had been treated with this human antiserum, and twenty-six recovered. The serum was injected into the patients within forty-eight hours of the pneumonia's start.

To every cloud there is a silver lining. This terrible epidemic has at least brought with it one benefit to humanity. For the first time in thousands of years there at last appears a ray of light to help us toward the conquest of one of man's most deadly and dangerous enemies—pneumonia.

EDITORIAL NOTE—It is to be hoped that the epidemic of the so-called Spanish influenza will be over when this magazine appears. It is unfortunately the fact, however, that after apparently losing its virulence, the disease sometimes flares up again. For instance, as we were about to go to press, on November 18, the newspapers reported a serious new outbreak in Indianapolis.

In any case, our readers may be interested in this article by Dr. Hirshberg, a B A. and M.D. of Johns Hopkins, and author of the article on " The War Service of Our American Doctors,'" printed in Munsey's Magazine for July 1918.

Recently published statistics show that in New York, during the epidemic stage of the disease, there were 128,558 reported cases of influenza and 19,001 of pneumonia, with 20,086 deaths from the two causes. In forty-six cities of the United States, with a combined population of twenty-three million, there were reported between September 9 and November 9, 1918, 82,306 deaths from influenza and pneumonia—fully 78,000 above the normal figure for fatalities from those causes.

In the present imperfect state of American vital statistics it is not possible to get any figure for the whole country, but from these rather scanty data it may be roughly estimated that the epidemic has killed something like half a million people since it reached the United States—in other words, about ten times as many as our total fatalities from all causes in the great war.

Leonard Keene Hirshberg, M.D., "The Spanish Influenza," in Munsey's Magazine, New York: The Frank A. Munsey Company, Publishers, Vol. LXV, No. 4, January 1919, pp. 664-668.

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