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diff --git a/.gitattributes b/.gitattributes new file mode 100644 index 0000000..d7b82bc --- /dev/null +++ b/.gitattributes @@ -0,0 +1,4 @@ +*.txt text eol=lf +*.htm text eol=lf +*.html text eol=lf +*.md text eol=lf diff --git a/LICENSE.txt b/LICENSE.txt new file mode 100644 index 0000000..6312041 --- /dev/null +++ b/LICENSE.txt @@ -0,0 +1,11 @@ +This eBook, including all associated images, markup, improvements, +metadata, and any other content or labor, has been confirmed to be +in the PUBLIC DOMAIN IN THE UNITED STATES. + +Procedures for determining public domain status are described in +the "Copyright How-To" at https://www.gutenberg.org. + +No investigation has been made concerning possible copyrights in +jurisdictions other than the United States. Anyone seeking to utilize +this eBook outside of the United States should confirm copyright +status under the laws that apply to them. diff --git a/README.md b/README.md new file mode 100644 index 0000000..f9f66eb --- /dev/null +++ b/README.md @@ -0,0 +1,2 @@ +Project Gutenberg (https://www.gutenberg.org) public repository for +eBook #60087 (https://www.gutenberg.org/ebooks/60087) diff --git a/old/60087-0.txt b/old/60087-0.txt deleted file mode 100644 index beeda68..0000000 --- a/old/60087-0.txt +++ /dev/null @@ -1,1357 +0,0 @@ -Project Gutenberg's Influenza, by Provincial Board of Health Ontario - -This eBook is for the use of anyone anywhere at no cost and with -almost no restrictions whatsoever. You may copy it, give it away or -re-use it under the terms of the Project Gutenberg License included -with this eBook or online at www.gutenberg.org/license - - -Title: Influenza - -Author: Provincial Board of Health Ontario - -Release Date: August 11, 2019 [EBook #60087] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK INFLUENZA *** - - - - -Produced by Richard Tonsing and the Online Distributed -Proofreading Team at http://www.pgdp.net (This file was -produced from images generously made available by The -Internet Archive) - - - - - - - - - - Department of the Provincial Secretary - -[Illustration: ONTARIO] - - PROVINCIAL BOARD OF HEALTH - - - - - INFLUENZA - - - TORONTO: - - Printed and Published by A. T. WILGRESS, Printer to the King’s Most - Excellent Majesty - 1919 - - - - - INFLUENZA - - -The Provincial Board of Health deems it advisable that the statement -issued by the American Public Health Association, following the recent -meeting in Chicago should be in the hands of the medical profession of -Ontario. Consequently this statement is herein given in full. - -As there is considerable difference of opinion among health officers, -the profession and the public, with reference to the value of measures -of prevention, such as the placarding and quarantine of premises where -the disease exists, the Board has deemed it of sufficient importance to -add some remarks giving the views of provincial and state officers of -health in this respect as well as upon other points of interest. - -With the view of learning the experience of the state and provincial -health officers of the United States and Canada the Board addressed the -following inquiry to all such officers, viz.:—“Does your province (or -state) require the reporting, placarding and quarantine of influenza, -and, if so, do you consider placarding and quarantine of such, -practicable?” - -Replies were received from the health officers of the nine Canadian -provinces and from 43 state health officers. Four of the provinces of -Canada reported that placarding and quarantine of influenza was -impracticable. One states that “modified quarantine was working fairly -well,” another said that “the law was not well obeyed,” a third stated -“almost impossible in rural places,” and a fourth “many infractions but -believe good effect,” a single officer only declared it practicable. - -Of the reports from United States’ health officers, 29 out of the 43 or -67 per cent. state that placarding and quarantine in influenza are -impracticable. Of the remainder of the replies nine report the law -practicable, and five qualify their statement by such expressions as -“seems to be of value,” “enforcement depends on local sentiment,” “law -fairly obeyed,” “beneficial,” “believe quarantine should be included.” - -Thus it will be seen that out of 52 health officers of the states and -provinces of North America, 9 frankly state, as the result of their -experience, that placarding and quarantine are practicable, 10 qualify -their approval, and _33 frankly state that these measures are -impracticable_. - -The real facts, considering the views of the American Public Health -Association as well as of the public health authorities of the two -countries, seem to be, as Sir Arthur Newsholme, Chief Medical Officer of -the Local Government Board of England, says, “I know of no public health -measures which can resist the progress of pandemic influenza.” And, as -remarked by Dr. Victor Vaughan at the recent meeting, “I say that, in -the face of the greatest pestilence that ever struck this country, we -are just as ignorant as the Florentines were with the plague described -in history.” - -The Chairman of the Provincial Board says: “If our patients are put to -bed immediately they feel the first symptoms of the disease and kept -there for 5 days after the temperature falls, they will, in the large -percentage of cases, recover.” - - - - - INTRODUCTORY STATEMENT. - - -The present epidemic is the result of a disease of extreme -communicability. So far as information available to the committee shows, -the disease is limited to human beings. - -The micro-organism of virus primarily responsible for this disease has -not yet been identified. There is, however, no reason whatsoever for -doubting that such an agency is responsible for it. Mental conditions -may cause one to believe he has influenza when he has not, and may make -the patient who has the disease suffer more severely than he otherwise -would. No mental state alone, however, will cause the disease in one who -is not infected by the organism or virus that underlies the malady. - -While the prevailing disease is generally known as influenza, and while -it will be so referred to in this statement, it has not yet been -satisfactorily established that it is the identical disease heretofore -known by that name, nor has it been definitely established that all -preceding outbreaks of disease styled at the time “influenza” have been -outbreaks of one and the same malady. - -There is no known laboratory method by which an attack of influenza can -be differentiated from an ordinary cold or bronchitis or other -inflammation of the mucous membranes of the nose, pharynx, or throat. - -There is no known laboratory method by which it can be determined when a -person who has suffered from influenza ceases to be capable of -transmitting the disease to others. - -Laboratories are necessary agencies for the supervision and ultimate -control of the disease. The research laboratory is necessary for the -discovery of the causative micro-organism or virus, and for the -discovery of some practicable method for the propagation of a specific -vaccine and a curative serum. Clinical laboratories are necessary for -the supervision and control of such vaccines and sera as may be used -from time to time for the prevention of the disease and for therapeutic -purposes, and for the information such laboratories can give to health -officers and physicians as to such variations in the types of infective -micro-organisms, as occur during the progress of an epidemic. - -Deaths resulting from influenza are commonly due to pneumonias resulting -from an invasion of the lungs 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. This invasion is apparently secondary -to the initial attack. - -Evidence seems conclusive that the infective micro-organism or virus of -influenza is given off from the nose and mouth 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. - - - - - PREVENTION. - - -If it be admitted that influenza is spread solely through discharges -from the noses 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. - - I. Break the channels of communication by which the infective agent - passes from one person to another. - - II. Render persons exposed to infection immune, or at least more - resistant, by the use of vaccines. - - III. Increase the natural resistance of persons exposed to the - disease, by augmented healthfulness. - - -_I. Breaking the channels of communication._ - - (a) By preventing droplet infection. The evidence offered indicates - that this is of prime importance. - - (b) By sputum control. The evidence offered indicates that the danger - here is due chiefly to contamination of the hands and common eating - and drinking utensils. - - (c) By supervision of food and drink. Evidence offered does not - indicate much danger of infection through these channels. - -Details and practical methods possible for the limitation of infection -through droplets, sputum, and food and drink are discussed later under -special preventive methods. - - -_II. Immunization and vaccines._ - - (See the report of the laboratory committee appended.) - - In the present epidemic vaccines have been used to accomplish: - - 1. The prevention or mitigation of influenza _per se_. - - 2. The prevention or mitigation of complications recognized as due to - the influenza bacillus or to various strains of streptococci and - pneumococci. - -In relation to the use of vaccines for the prevention of influenza, the -evidence which has come to the attention of the committee as to the -success or lack of success of the practice is contradictory and -irreconcilable. In view of the fact that the causative organism is -unknown, there is no scientific basis for the use of any particular -vaccine against the primary disease. If used, any vaccine must be -employed on the chance that it bears a relation to the unknown organism -causing the disease. - -The use of vaccines for the complicating infections rests on more -logical grounds, and yet the committee has not sufficient evidence to -indicate that they can be used with any confident assurance of success. -In the use of these vaccines the patient should realize that the -practice is still in a developmental stage. - -The committee believes that when vaccines are used experimentally for -the purpose of determining their preventive or curative value, the -following conditions should be complied with: - - 1. The groups of vaccinated and unvaccinated persons should be the - same in number. - - 2. The relative susceptibilities of the two groups should be equal, as - measured by age and sex distribution, previous exposure to infection - without development of influenza and a previous history as to recent - attacks of the disease. - - 3. The degree of exposure in each group should be practically the same - in duration and intensity. - - 4. The groups should be exposed concurrently during the same stage of - the epidemic curve. - - -III. _Increased natural resistance of persons exposed to infection._ - -Physical and nervous exhaustion should be avoided by paying due regard -to rest, exercise, physical and mental labor, and hours of sleep. The -evidence is conclusive, however, that youth and bodily vigor do not -guarantee immunity to the disease. - -The nature of the preventive measures practicable and necessary in any -given community depends in a large part upon the nature of the community -itself, as to population characteristics, industries, and so on, and -upon the stage and type of the epidemic curve. For example, the measures -to be adopted in a purely rural community would not be practicable or -desirable in a large metropolitan area, nor would the measures desirable -and feasible at the beginning or end of an epidemic be found those best -adapted for the intervening period. The committee has found it -impossible, therefore, to lay down any rules for the guidance of all -health officials alike in preventive measures. The most it has been able -to do has been to state certain general principles that in its judgment -should underlie administrative measures for the prevention of influenza. -The application of these principles to the needs of any particular -community must be left for determination by the officers of that -community who are responsible for the protection of its public health. - -The preventive measures recommended by the committee are as follows: - -A. Efficient organization to meet the emergency, providing for a -centralized co-ordination and control of all resources. - -B. Machinery for ascertaining all facts regarding the epidemic: - - 1. Compulsory reporting. - - 2. A lay or professional canvass for cases, etc. - -C. Widespread publicity and education with respect to respiratory -hygiene, covering such facts as the dangers from coughing, sneezing, -spitting, and the careless disposal of nasal discharges; the -advisability of keeping the fingers and foreign bodies out of the mouth -and nose; the necessity of hand-washing before eating; the dangers from -exchanging handkerchiefs; and the advantages of fresh air and general -hygiene. Warnings should be given regarding the danger of the common -cold, and possibly cold should be made reportable so as to permit the -sending of follow up literature to persons suffering from them. The -public should be made acquainted with the danger of possible carriers -among both the sick and the well and the resultant necessity for the -exercise of unusual care on the part of everybody with respect to the -dangers of mouth and nasal discharges. - -D. Administrative procedures: - -1. There should be laws against the use of common cups, and improperly -washed glasses at soda fountains and other public drinking places, which -laws should be enforced. - -2. There should be proper ventilation laws, which laws should be -enforced. - -Since the disease is probably largely a group or crowd problem, the -three following sub-heads are especially important. - -3. CLOSING.—Since the spread of influenza is recognized as due to the -transmission of mouth and nasal discharges from persons infected with -influenza, some of whom may be aware of their condition but others -unaware of it, to the mouths and noses of other persons, gatherings of -all kinds must be looked upon as potential agencies for the transmission -of the disease. The limitation of gatherings with respect to size and -frequency, and the regulation of the conditions under which they may be -held must be regarded, therefore, as an essential administrative -procedure. - -Non-essential gatherings should be prohibited. Necessary gatherings -should be held under such conditions as will insure the greatest -possible amount of floor space to each individual present, and a maximum -of fresh air, and precautions should be taken to prevent unguarded -sneezing, coughing, cheering, etc. - -Where the necessary activities of the population, such as the -performance of daily work and earning of a living, compel considerable -crowding and contact, but little is gained by closing certain types of -meeting places. If, on the other hand, the community can function -without much of contact between individual members thereof, relatively -much is gained by closing or preventing assemblages. - -SCHOOLS: As to the closing of schools there are many questions to be -considered. - - (a) Theoretically, schools increase the number and degree of contacts - between children. If the schools are closed, many of the contacts - which the children will make are likely to be out of doors. Whether or - not closing will decrease or increase contacts must be determined - locally. Obviously, rural and urban conditions differ radically in - this regard. - - (b) Are the children in coming to and going from school exposed to - inclement weather or long rides in overcrowded cars? - - (c) Is there an adequate nursing and inspection system in the schools? - - (d) Is it likely that teachers, physicians and nurses can really - identify and segregate the infected school child before it has an - opportunity to make a number of contacts in halls, yards, rooms, etc.? - We suggest that children suspected of having influenza and held in - school buildings for inspection should be provided with and required - to wear face masks. - - (e) Will the closing of schools release personnel or facilities to aid - in fighting the epidemic? - - (f) If schools are kept open, will the absence of many teachers lower - the educational standards? - - (g) If a number of pupils stay at home because of illness or fear, - will they not constitute a heavy drag upon their classes when they - return? - - (h) If schools are closed, is there likely to be an outbreak in any - case when they are reopened? - -CHURCHES: If churches are to remain open, services should be reduced to -the lowest number consistent with the adequate discharge of necessary -religious offices, and such services as are held should be conducted in -such a way as to reduce to a minimum intimacy and frequency of personal -contact. - -THEATRES: As regards theatres, movies, and meetings for amusement in -general, it seems unwise to rely solely or in great part upon the -ejection of careless coughers. In the first place it is difficult to -determine who is a careless cougher, and after each cough, danger has -already resulted. It seems, too, that the closing of theatres may have -as much educational value as their use for direct educational purposes, -etc. Discrimination as to closing among theatres, movies, etc., on the -basis of efficiency of ventilation and general sanitation, may be -feasible. - -SALOONS, ETC.: The closing of saloons and other drinking places should -be decided upon the basis of the probability of spread of the disease -through drinking utensils and the conditions of crowding. - -DANCE HALLS, ETC.: The closing of dance halls, bowling rooms, billiard -parlors and slot-machine parlors, etc., should be made effective in all -cases where their operation causes considerable personal contact and -crowding. - -STREET CARS, ETC.: Ventilation and cleanliness should be insisted upon -in all transportation facilities. Over-crowding should be discouraged. A -staggering of opening and closing hours in stores and factories to -prevent overcrowding of transportation facilities may be cautiously -experimented with. In small communities where it is feasible for persons -to walk to their work it is better to discontinue the service of local -transportation facilities. - -FUNERALS: Public funerals and accessory funeral functions should be -prohibited, being unnecessary assemblies in limited quarters, increasing -contacts and possible sources of infection. - -4. MASKS.—The wearing of proper masks in a proper manner should be made -compulsory in hospitals and for all who are directly exposed to -infection. It should be made compulsory for barbers, dentists, etc. The -evidence before the committee as to beneficial results consequent upon -the enforced wearing of masks by the entire population at all times was -contradictory, and it has not encouraged the committee to suggest the -general adoption of the practice. Persons who desire to wear masks, -however, in their own interest, should be instructed as to how to make -and wear proper masks, and encouraged to do so. - -5. ISOLATION.—The isolation of patients suffering from influenza should -be practised. In cases of unreasonable carelessness, it should be -legally enforced most rigidly. - -6. PLACARDING.—In cases of unreasonable carelessness and disregard of -the public interests placarding should be enforced. - -7. HOSPITALIZATION.—The theory of complete hospitalization is that, if -all the sick were hospitalized the disease would be controlled. In -certain somewhat small communities where hospitalization of all cases -was promptly inaugurated the disease did come quickly under control. It -must be recognized, however, that unless every infective person can be -detected and identified as such and removed to the hospital before he -has infected others, hospitalization cannot be depended upon to -eliminate the disease. - -In general, home treatment is to be advocated where medical, nursing and -other necessary facilities are adequate, and where home treatment is not -directly contra-indicated by the danger of infecting others. The -hospitalization in any case, mild or severe, should be undertaken only -when facilities for home treatment are inadequate with respect to -medical and nursing care or otherwise. The objection to routine -hospitalization of mild cases lies in the fact that patients not already -suffering from secondary infections may acquire them by exposure to -hospital cases already so infected. The objection to the routine -hospitalization of severe cases lies in the danger to the patient -necessarily incident in the transfer from home to hospital. - -8. COUGHING AND SNEEZING.—Laws regulating coughing and sneezing seem to -be desirable for educational and practical results. - -9. TERMINAL DISINFECTION.—Terminal disinfection for influenza has no -advantage over cleaning, sunning and airing. - -10. ALCOHOL.—The use of alcohol serves no preventive purpose. - -11. SPRAYS AND GARGLES.—Sprays and gargles do not protect the nose and -throat from infection, for the following reasons: - - (a) So far as the knowledge of the committee extends, no germicide - strong enough to destroy infective organisms can be applied to the - nose and throat without at the same time injuring the mucous - membranes. - - (b) Irrigation of the nose and throat to accomplish the complete - mechanical removal of the infective organism is impracticable. - - (c) Their use tends to remove the protective mucus, to spread the - infection and to increase the liability of actual entrance of the - infective organisms. - - (d) Their domestic use is liable to lead in families to a common - employment of the same utensils. - - (e) The futility of sprays and gargles has been demonstrated with - respect to certain known organisms such as the diphtheria bacillus and - the meningococcus. - - - - - MISCELLANEOUS CONSIDERATIONS. - - -1. Colleges, asylums and similar establishments may with advantage -enforce rigid institutional quarantine against the outside world, if -they begin in the early stage of an epidemic, provided they are so -located and conducted as to render the procedure reasonably likely to be -effective, even temporarily; for even temporary success will postpone -the appearance of the disease, if it appears at all, to a time when the -patients will be more likely to be able to have adequate medical and -nursing care. - -2. The recommended measures for control, even if they do not accomplish -the desired end, should at least be instrumental in distributing the -epidemic over a longer period of time, which in itself is highly -desirable. - -3. The statistics of the disease and the keeping of proper records are -extremely important. The lack of knowledge regarding innumerable factors -in reference to the disease makes all the more desirable complete case -records, etc. - -4. The committee wishes to emphasize the need for the complete -statistical study of the collected data on the mortality, morbidity, -case fatality, duration, economic aspects, and therapeutics of the -disease. Through the collection of the facts in a uniform manner, and -through the analysis of such tabulated data, especially mathematical -graduation, and testing and study of the figures, important -contributions to the natural history and typical characters of the -disease may be expected. General principles as to the etiology, fatality -and practical management of influenza may follow from the extensive -survey of the epidemic in the statistical laboratory as well as from the -intensive bedside observation of single cases of the disease. - -5. The measures recommended are calculated to be effective in the -promotion of respiratory hygiene in general and particularly in the -control of pneumonia and other respiratory infections. - - - - - ADMINISTRATIVE MEASURES FOR RELIEF. - - -The committee on administrative measures for relief would submit the -following considerations as constituting a summary of the important -measures for meeting epidemic conditions: - - -_I. General Rules._ - -1. Compulsory reporting. - -2. Isolation by co-operation and education, to a point where it does not -diminish the willingness of the physician to report. - -3. Placarding would seem to be subject to the same limitations as is -isolation. - -4. The closing of schools, prohibition of funerals, etc., being -preventive measures, are not touched upon in this report, except to -mention that the closing of many agencies will release medical, nursing, -and volunteer services for special influenza work. - -5. It may be necessary to grant authority and power to the health -authorities to administer relief. - - -_II. Preliminary Measures._ - -1. The listing and distribution of resources, including physicians, -nurses, social workers, nurses’ aids, clerks, domestics, laundresses, -automobiles, chauffeurs, mask makers, and volunteers of all kinds. - -All available publicity channels should be used to promote volunteer -service. - -An appeal should be made for voluntary donors of human blood serum from -convalescent influenza patients, to be held in readiness for use in -treatment. - -2. The centralization of resources, under one control, with central and -branch headquarters, the city being districted for medical, nursing and -other work. - -The central headquarters should be ordinarily under the supervision of a -board representative of the most important agencies concerned, the -board’s work to be administered through a manager (presumably the health -officer) selected for his fitness. - -3. The service should be maintained on a 24–hour basis, and a system of -outgoing and incoming telephone service is essential. - -4. The local authorities should get and keep in touch with state and -national agencies. - - -_III. Current and Continuous Analysis of Case Situation._ - -1. In the smaller communities a canvass should be made of all -physicians, soliciting information as follows: - - (a) Number of cases under care. - - (b) Number of cases needing hospital treatment. - - (c) Number of cases needing home nursing care. - - (d) Number of cases requesting medical service but not reached. - -This information will indicate the situation as regarding the need for -emergency nursing and medical service, and should be acquired as fully -as possible in larger communities, through various agencies such as a -current lay or police canvass of homes, etc. The continuous -classification of cases according to these groupings is of practical -value. - - -_IV. Analysis, Augmentation and Organization of Principal Facilities._ - - -(A) _Field Nursing._ - -1. Ordinarily nursing facilities utilized in general public health work -should be diverted to meet the epidemic situation, and should be used on -a district basis, with all other available facilities, under one -supervision. - -2. Nursing assistants, volunteers, etc., should be used wherever -possible in homes and institutions, under expert supervision, after -classification and assignment on a basis of minimum standards as to -fitness, and such intensive training in the care of influenza and -pneumonia patients as may be feasible. - -3. From the standpoint of the patient, home treatment is to be -advocated, if medical, nursing, disease preventive and other facilities -are adequate. - -4. Restriction so far as possible through the pressure of public opinion -should be brought against the unnecessary use of private nurses. - -5. Automobile transportation should be provided, and the nursing service -used to encourage isolation and education. - -6. Special record forms are essential for this and the medical work, and -a special sub-committee is proposed to meet this problem. - -7. Provision as to housing and care should be made for out of town -nurses. - -8. We recommend further training with reference to influenza for all -graduates of Red Cross Home nursing courses and more extensive use of -their services. This would necessitate frequent and careful registration -(names, addresses and telephone numbers) and further information -regarding personal health, age and ability and willingness to serve. - - -(B) _Emergency Medical Service._ - -1. The medical service should be handled through the central office, the -physicians being responsible to the central office, though perhaps -assigned to district offices. - -2. In this emergency service there should be utilized all available -physicians such as school and factory physicians, volunteers, -practitioners on a paid basis, fourth year medical students, etc. This -service should cover all calls reported as unreached by private -physicians or received through other channels, and should be -co-ordinated with the special nursing service, being provided with -automobile transportation, machines being hired if necessary. - -3. The emergency medical service should be used to select cases needing -hospital care. - -4. It may be feasible to institute a central clearing house in certain -districts for private physicians’ calls. - -5. An arrangement should be made through the medical licensing board for -granting of temporary permits to practise to reputable physicians from -out of the state, at the request of the Central Influenza Committee. - -6. In some localities it may be feasible to district the local -practitioner and to have him meet special calls on a part time basis for -adequate compensation. - -7. Certain of the relatively non-essential specialties should be -discouraged, and the physician in those specialties urged to volunteer -for emergency district work. This type of service may be operated on a -pay or free basis. - -8. Presumably some effort should be made, through an authoritative -medical commission, to suggest standard methods of treatment, and wise -limitations as to therapeutic procedure. - - -(C) _Hospital Facilities._ - -1. It is essential that the facilities, if possible, be kept ahead of -the demand. A daily canvass should be made and data collected regarding -available beds, medical and nursing needs, domestics, food, cots, -supplies, etc. A regular visit by an inspector will probably prove more -effective than an attempt at telephone communication. - -2. Under most conditions a central clearing house, covering most if not -all of the hospitals, is advisable for the admission of cases. Through -this channel the severer cases may receive first consideration. Owing to -constant changes in the hospital bed situation, the daily canvass of -facilities may not be wholly depended upon; on the contrary, it may -usually be necessary to telephone the hospital in order to make sure -regarding the admission of a particular case. In any event the -hospitals, if facilities are inadequate, should be impressed with the -necessity for admitting only the most severe or needy cases, pay or -free. Special hospital arrangements should be provided for pregnant -women. - -3. It is advisable to add wards or tents or new equipment to existing -institutions rather than to establish entirely new emergency hospitals. -If practicable, certain hospitals may be urged to handle influenza cases -exclusively. - -4. Non-emergency surgical and chronic medical cases amenable to home -treatment should be de-hospitalized. - -5. A convalescent home, if adjacent to the hospital, may serve for the -care of mild and convalescent cases, thereby increasing the space in the -hospital for acute cases, obviously involving an increase in the nursing -facilities. - -6. A canvass of ambulance facilities should be made, ambulances being -requisitioned with payment, or hired by contract, if necessary. -Automobiles and motor trucks should be potentially mobilized for this -purpose. Frequently military equipment may be used if accessible. - - -_V. Social and Relief Measures._ - -1. The central office should keep the family advised regarding the -patient, thereby saving telephone calls, trolley fares and worry on the -part of the family, and thereby increasing the willingness for -hospitalization. - -2. Volunteer workers such as Red Cross volunteers, teachers, relatives, -etc., should be placed in care of families where the responsible members -are dead or hospitalized, this service being under expert social -supervision, and the families in touch with the supply system. -Supervision of placed-out children is also necessary. - -3. Homes should be investigated before patients are discharged into -them, when destitution or other untoward circumstances are apparent. - -4. Precaution should be taken that institutions and families too busy -with the influenza situation to look after their own needs, are covered -by the general relief measures. - -5. Ordinary charitable relief should be handled through the routine -agencies, the service co-ordinated with the other epidemiological -measures. Churches, lodges, etc., should be urged to handle their own -cases, in order to relieve the pressure on the central agency. Aid -should be immediate, without protracted investigation. - -6. Recreation facilities (motoring, etc.) should be provided for the -physicians and nurses while off duty. - - -_VI. Food._ - -1. Available central cooking facilities should be used so far as is -necessary, such as the dietetic equipment in high schools, normal -schools, colleges, etc., with a delivery system to families and -institutions in need. - -2. Individual families should be encouraged to cook additional amounts, -the same to be delivered to central diet kitchens for distribution, a -standard list of prepared foods needed being devised and advertised, -with recognition of racial customs and preferences. - -3. It may be necessary to establish canteens in sections of the city. - - -_VII. Laundry._ - -1. A special collection and distribution system may be essential both -for homes and institutions. - -2. It may be necessary to take over a public laundry with compensation, -or a private non-medical institution laundry. - - -_VIII. Provision for Fatalities._ - -1. Death reporting should be prompt (24 hours) and a record kept so as -to ensure prompt disposal of bodies. - -2. A daily canvass of available coffins should be made, labor assured -for construction, and possibly no coffins sold without the permit of the -Influenza Administration Office. - -3. If morgue facilities are inadequate a central place should be -provided, with embalming facilities, for the temporary disposal of -bodies. - -4. A canvass of hearses should be made and regulations issued -prohibiting unnecessarily long hauls, insisting on maximum capacity -loads, etc. A central control will prevent unnecessary duplication as to -routes, etc. - -5. A reserve supply of trucks and automobiles should be at hand for use -in various ways in connection with the handling of fatal cases. - -6. The number of graves required should be estimated and labor released -from public works or secured through other channels (possibly military) -for digging. Possibly temporary trench interment may be necessary. - - -_IX. Education, Instruction and Publicity._ - -Literature and special instructions will be necessary on many phases, -including the following: - -1. Instructions to physicians as to reporting, facilities available, -district arrangements, etc. - -2. Advice to physicians regarding treatment standards and suggestions. - -3. Instructions for families, to be distributed by nurses, physicians, -social workers, druggists, etc., covering the problems of care during -the physician’s absence. - -4. Instructions to the public as to where aid may be secured, to be -printed in various languages, and distributed by druggists, displayed in -street cars, used in the press, etc. - -5. Instructions for families on “What to do till the doctor comes.” - -6. Instructions to physicians, factory managers, school superintendents, -etc., urging the necessity for immediate home and bed treatment at the -first sign of respiratory disease. - -7. Popular literature on the essentials of adequate care, the danger of -returning to work too soon, etc. Popular press space is worth paying -for, if it cannot be secured otherwise. - -8. Popular publicity as to legitimate medical, nursing, undertaker, -drug, and other charges, to prevent profiteering. - - -_X. Miscellaneous._ - -1. The co-operation of pharmaceutical agencies should be secured to -ensure an adequate supply of drugs and druggists. - -2. Influenza victims and their families should have “first call” on fuel -deliveries. - -3. While follow up procedures are not legitimately a factor in the -epidemic situation, their consideration is essential to an adequate -meeting of the entire problem. This means adequate provision for medical -examination and nursing care, relief measures, industrial employment -problems, the follow up of special sequelæ such as cardiac affections, -tuberculosis, etc. - -4. It is finally suggested that Health Department draw up a programme -based on the above outline, holding it in reserve for future use, if not -immediately needed, and modifying the proposal to fit the size and other -characteristics of the particular community. - - - - - THE BACTERIOLOGY OF THE 1918 EPIDEMIC OF SO-CALLED INFLUENZA. - - -The epidemic disease known as influenza is believed to be due to an -undetermined organism which causes an infection that lowers the -resistance of the body as a whole, and of the respiratory organs in -particular. This allows the invasion of other pathogenic -micro-organisms. The most important complicating infections are due to -the influenza bacilli, different strains of pneumococci and different -varieties of streptococci. Some careful observers regard certain of -these organisms as the primary cause. - -In each case, one or several of these micro-organisms may be present. In -different portions of the country the dominating variety of organism has -been found to differ. - - - - - VACCINES. - - -Assuming that the cause of the epidemic is an unknown virus, it does not -seem possible at present to prevent the primary disease by vaccination -with known organisms. Against the secondary infections, there would seem -to be a theoretical basis for the use of vaccines, and especially for -the use of vaccines prepared from organisms responsible for -complications which may differ in various localities at various times. -This variable bacterial flora may militate against the practical -application of vaccination on a large scale, because it would seem to -require frequently repeated vaccinations with the flora that may be met -with. It is impossible at present to evaluate the reports from the use -of these vaccines adjusted to meet local conditions. More data obtained -under carefully controlled conditions are needed. - -Stock vaccines made from the influenza bacillus alone or from other -bacteria, have been used to considerable extent. The injections of stock -vaccines have seemed to mitigate to some degree some outbreaks of -influenza and also the severity of the complicating infections; but in -those instances in which the results of the use of vaccine have been -controlled, no appreciable results have been obtained. The fact that the -vaccine is usually employed after the epidemic has broken out and is -perhaps on a decline, and the fact that an unknown number of people have -been exposed, make it very difficult to draw conclusions as to its -efficacy. - - - - - RECOMMENDATIONS. - - -Your committee recommends that until such time as the efficacy, or the -lack of efficacy, of prophylactic vaccination against influenza is -established, vaccine if used, should be employed in a controlled manner, -under conditions that will allow a fair comparison of the number of -cases and of deaths among the vaccinated and non-vaccinated groups. -Particular attention should be directed to securing data as to the -period in the epidemic at which vaccinated and non-vaccinated persons -developed the disease. - -Your committee is of the opinion that the indiscriminate use of stock -vaccines against influenza and influenza and pneumonia cannot be -recommended. - -Nothing in these recommendations should be interpreted as discouraging -the use of a pneumococcus stock vaccine against lobar pneumonia. - -This epidemic emphasizes the importance of properly equipped -laboratories. - - - - - HISTORY AND STATISTICS OF THE EPIDEMIC. - - -Your sub-committee wishes to say that in view of the fact that the -historical and other data of the epidemic are still in process of -collection, no positive statement can be made at the present time on the -precise incidence of the disease in the American population. On the -basis of the best data available your sub-committee estimates that there -were not less than 400,000 deaths from the disease in the United States -during the months of September, October and November, 1918. The major -portion of this mortality occurred at ages 20–40, when human life is of -the highest economic importance. We would suggest that this -sub-committee be authorized to co-operate with the special committee on -statistical study of the epidemic of the section on Vital Statistics of -this Association, and that the data collected through that latter -special committee be reported through the sub-committee on history and -statistics of the epidemic to the general reference committee on the -influenza epidemic. Standard forms for purposes of statistical -tabulation, analysis and graphic presentation will be submitted in a -supplementary report at an early date. - - - - - SUGGESTIONS. - - -In view of the probability of recurrences of the disease from time to -time during the coming year, health departments are advised to be ready -in advance with plans for prevention, which plans shall embody the -framework of necessary measures and as much detail as possible. Laws -plainly necessary should be enacted and rules passed now. Emergency -funds should be held in reserve or placed in special appropriations, -which appropriations can be quickly made available for influenza -prevention work. - -The probability that as an after effect of the influenza epidemic there -will be an unusually high pneumonia rate for several years should be -taken into consideration. - -Of measures for the control of the disease, bacteriologic studies as to -the nature of the organisms causing the primary infection and as to -bacteria associations, new and improved procedures leading to the -production and use of effective vaccines and curative sera, and the -fresh air treatment of the infected, appear to offer most promise. - ------------------------------------------------------------------------- - - - - - TRANSCRIBER’S NOTES - - - 1. Silently corrected typographical errors and variations in spelling. - 2. Retained anachronistic, non-standard, and uncertain spellings as - printed. - 3. 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- } - .covernote { visibility: hidden; display: none; } - div.tnotes p { text-align:left; } - @media handheld { .covernote { visibility: visible; display: block;} } - .section { clear: both; page-break-before: always; } - .ol_1 li {font-size: .9em; } - @media handheld {.ol_1 li {padding-left: 1em; text-indent: 0em; } } - body {font-family: Georgia, serif; text-align: justify; } - table {font-size: .9em; } - .figcenter {font-size: .9em; } - div.titlepage {text-align: center; page-break-before: always; - page-break-after: always; } - div.titlepage p {text-align: center; text-indent: 0em; font-weight: bold; - line-height: 1.5; margin-top: 3em; } - .ph1 { text-indent: 0em; font-weight: bold; font-size: xx-large; - margin: .67em auto; page-break-before: always; } - </style> - </head> - <body> - - -<pre> - -Project Gutenberg's Influenza, by Provincial Board of Health Ontario - -This eBook is for the use of anyone anywhere at no cost and with -almost no restrictions whatsoever. You may copy it, give it away or -re-use it under the terms of the Project Gutenberg License included -with this eBook or online at www.gutenberg.org/license - - -Title: Influenza - -Author: Provincial Board of Health Ontario - -Release Date: August 11, 2019 [EBook #60087] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK INFLUENZA *** - - - - -Produced by Richard Tonsing and the Online Distributed -Proofreading Team at http://www.pgdp.net (This file was -produced from images generously made available by The -Internet Archive) - - - - - - -</pre> - - -<div class='tnotes covernote'> - -<p class='c000'><b>Transcriber’s Note:</b></p> - -<p class='c000'>The cover image was created by the transcriber and is placed in the public domain.</p> - -</div> - -<div class='titlepage'> - -<div class='nf-center-c0'> -<div class='nf-center c001'> - <div><span class='xlarge'><span class='under'>Department of the Provincial Secretary</span></span></div> - </div> -</div> - -<div class='figcenter id001'> -<img src='images/title.jpg' alt='' class='ig001' /> -<div class='ic001'> -<p>ONTARIO</p> -</div> -</div> - -<div class='nf-center-c0'> - <div class='nf-center'> - <div><span class='large'>PROVINCIAL BOARD OF HEALTH</span></div> - </div> -</div> - -<div> - <h1 class='c002'>INFLUENZA</h1> -</div> - -<div class='nf-center-c0'> -<div class='nf-center c003'> - <div>TORONTO:</div> - <div class='c004'>Printed and Published by A. T. WILGRESS, Printer to the King’s Most Excellent Majesty</div> - <div>1919</div> - </div> -</div> - -</div> - -<div><span class='pageno' id='Page_2'>2</span></div> -<div class='section ph1'> - -<div class='nf-center-c0'> -<div class='nf-center c001'> - <div>INFLUENZA</div> - </div> -</div> - -</div> - -<p class='c005'>The Provincial Board of Health deems it advisable that the statement issued -by the American Public Health Association, following the recent meeting in -Chicago should be in the hands of the medical profession of Ontario. Consequently -this statement is herein given in full.</p> - -<p class='c006'>As there is considerable difference of opinion among health officers, the profession -and the public, with reference to the value of measures of prevention, such -as the placarding and quarantine of premises where the disease exists, the Board -has deemed it of sufficient importance to add some remarks giving the views of -provincial and state officers of health in this respect as well as upon other points -of interest.</p> - -<p class='c006'>With the view of learning the experience of the state and provincial health -officers of the United States and Canada the Board addressed the following inquiry -to all such officers, viz.:—“Does your province (or state) require the reporting, -placarding and quarantine of influenza, and, if so, do you consider -placarding and quarantine of such, practicable?”</p> - -<p class='c006'>Replies were received from the health officers of the nine Canadian provinces -and from 43 state health officers. Four of the provinces of Canada reported that -placarding and quarantine of influenza was impracticable. One states that -“modified quarantine was working fairly well,” another said that “the law was -not well obeyed,” a third stated “almost impossible in rural places,” and a fourth -“many infractions but believe good effect,” a single officer only declared it -practicable.</p> - -<p class='c006'>Of the reports from United States’ health officers, 29 out of the 43 or 67 -per cent. state that placarding and quarantine in influenza are impracticable. Of -the remainder of the replies nine report the law practicable, and five qualify their -statement by such expressions as “seems to be of value,” “enforcement depends on -local sentiment,” “law fairly obeyed,” “beneficial,” “believe quarantine should be -included.”</p> - -<p class='c006'>Thus it will be seen that out of 52 health officers of the states and provinces -of North America, 9 frankly state, as the result of their experience, that placarding -and quarantine are practicable, 10 qualify their approval, and <i>33 frankly -state that these measures are impracticable</i>.</p> - -<p class='c006'>The real facts, considering the views of the American Public Health Association -as well as of the public health authorities of the two countries, seem to be, as -Sir Arthur Newsholme, Chief Medical Officer of the Local Government Board of -England, says, “I know of no public health measures which can resist the progress -of pandemic influenza.” And, as remarked by Dr. Victor Vaughan at the recent -meeting, “I say that, in the face of the greatest pestilence that ever struck this -country, we are just as ignorant as the Florentines were with the plague described -in history.”</p> - -<p class='c006'>The Chairman of the Provincial Board says: “If our patients are put to bed -immediately they feel the first symptoms of the disease and kept there for 5 days -after the temperature falls, they will, in the large percentage of cases, recover.”</p> - -<div class='chapter'> - <span class='pageno' id='Page_3'>3</span> - <h2 class='c007'>INTRODUCTORY STATEMENT.</h2> -</div> - -<p class='c005'>The present epidemic is the result of a disease of extreme communicability. -So far as information available to the committee shows, the disease is limited to -human beings.</p> - -<p class='c006'>The micro-organism of virus primarily responsible for this disease has not -yet been identified. There is, however, no reason whatsoever for doubting that -such an agency is responsible for it. Mental conditions may cause one to believe -he has influenza when he has not, and may make the patient who has the disease -suffer more severely than he otherwise would. No mental state alone, however, will -cause the disease in one who is not infected by the organism or virus that underlies -the malady.</p> - -<p class='c006'>While the prevailing disease is generally known as influenza, and while it will -be so referred to in this statement, it has not yet been satisfactorily established -that it is the identical disease heretofore known by that name, nor has it been -definitely established that all preceding outbreaks of disease styled at the time -“influenza” have been outbreaks of one and the same malady.</p> - -<p class='c006'>There is no known laboratory method by which an attack of influenza can be -differentiated from an ordinary cold or bronchitis or other inflammation of the -mucous membranes of the nose, pharynx, or throat.</p> - -<p class='c006'>There is no known laboratory method by which it can be determined when a -person who has suffered from influenza ceases to be capable of transmitting the -disease to others.</p> - -<p class='c006'>Laboratories are necessary agencies for the supervision and ultimate control -of the disease. The research laboratory is necessary for the discovery of the causative -micro-organism or virus, and for the discovery of some practicable method -for the propagation of a specific vaccine and a curative serum. Clinical laboratories -are necessary for the supervision and control of such vaccines and sera as may -be used from time to time for the prevention of the disease and for therapeutic -purposes, and for the information such laboratories can give to health officers and -physicians as to such variations in the types of infective micro-organisms, as occur -during the progress of an epidemic.</p> - -<p class='c006'>Deaths resulting from influenza are commonly due to pneumonias resulting -from an invasion of the lungs 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. This invasion is apparently secondary to the initial attack.</p> - -<p class='c006'>Evidence seems conclusive that the infective micro-organism or virus of -influenza is given off from the nose and mouth 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.</p> - -<div class='chapter'> - <span class='pageno' id='Page_4'>4</span> - <h2 class='c007'>PREVENTION.</h2> -</div> - -<p class='c005'>If it be admitted that influenza is spread solely through discharges from the -noses 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.</p> - -<p class='c008'> I. Break the channels of communication by which the infective agent -passes from one person to another.</p> - -<p class='c008'> II. Render persons exposed to infection immune, or at least more resistant, -by the use of vaccines.</p> - -<p class='c008'>III. Increase the natural resistance of persons exposed to the disease, by -augmented healthfulness.</p> - -<h3 class='c009'><i>I. Breaking the channels of communication.</i></h3> - -<p class='c010'>(a) By preventing droplet infection. The evidence offered indicates that -this is of prime importance.</p> - -<p class='c008'>(b) By sputum control. The evidence offered indicates that the danger -here is due chiefly to contamination of the hands and common eating and -drinking utensils.</p> - -<p class='c008'>(c) By supervision of food and drink. Evidence offered does not indicate -much danger of infection through these channels.</p> - -<p class='c006'>Details and practical methods possible for the limitation of infection through -droplets, sputum, and food and drink are discussed later under special preventive -methods.</p> - -<h3 class='c009'><i>II. Immunization and vaccines.</i></h3> - -<p class='c010'>(See the report of the laboratory committee appended.)</p> - -<p class='c011'>In the present epidemic vaccines have been used to accomplish:</p> - -<p class='c008'>1. The prevention or mitigation of influenza <i><span lang="la" xml:lang="la">per se</span></i>.</p> - -<p class='c008'>2. The prevention or mitigation of complications recognized as due to the -influenza bacillus or to various strains of streptococci and pneumococci.</p> - -<p class='c006'>In relation to the use of vaccines for the prevention of influenza, the evidence -which has come to the attention of the committee as to the success or lack of success -of the practice is contradictory and irreconcilable. In view of the fact that the -causative organism is unknown, there is no scientific basis for the use of any particular -vaccine against the primary disease. If used, any vaccine must be employed -on the chance that it bears a relation to the unknown organism causing the disease.</p> - -<p class='c006'>The use of vaccines for the complicating infections rests on more logical -grounds, and yet the committee has not sufficient evidence to indicate that they can -be used with any confident assurance of success. In the use of these vaccines the -patient should realize that the practice is still in a developmental stage.</p> - -<p class='c006'><span class='pageno' id='Page_5'>5</span>The committee believes that when vaccines are used experimentally for the -purpose of determining their preventive or curative value, the following conditions -should be complied with:</p> - -<p class='c008'>1. The groups of vaccinated and unvaccinated persons should be the same -in number.</p> - -<p class='c008'>2. The relative susceptibilities of the two groups should be equal, as -measured by age and sex distribution, previous exposure to infection without -development of influenza and a previous history as to recent attacks of the -disease.</p> - -<p class='c008'>3. The degree of exposure in each group should be practically the same in -duration and intensity.</p> - -<p class='c008'>4. The groups should be exposed concurrently during the same stage of -the epidemic curve.</p> - -<h3 class='c009'>III. <i>Increased natural resistance of persons exposed to infection.</i></h3> - -<p class='c012'>Physical and nervous exhaustion should be avoided by paying due regard to -rest, exercise, physical and mental labor, and hours of sleep. The evidence is conclusive, -however, that youth and bodily vigor do not guarantee immunity to the -disease.</p> - -<p class='c006'>The nature of the preventive measures practicable and necessary in any given -community depends in a large part upon the nature of the community itself, as to -population characteristics, industries, and so on, and upon the stage and type of -the epidemic curve. For example, the measures to be adopted in a purely rural -community would not be practicable or desirable in a large metropolitan area, -nor would the measures desirable and feasible at the beginning or end of an -epidemic be found those best adapted for the intervening period. The committee -has found it impossible, therefore, to lay down any rules for the guidance of all -health officials alike in preventive measures. The most it has been able to do has -been to state certain general principles that in its judgment should underlie administrative -measures for the prevention of influenza. The application of these -principles to the needs of any particular community must be left for determination -by the officers of that community who are responsible for the protection of its public -health.</p> - -<p class='c006'>The preventive measures recommended by the committee are as follows:</p> - -<p class='c006'>A. Efficient organization to meet the emergency, providing for a centralized -co-ordination and control of all resources.</p> - -<p class='c006'>B. Machinery for ascertaining all facts regarding the epidemic:</p> - -<p class='c008'>1. Compulsory reporting.</p> - -<p class='c008'>2. A lay or professional canvass for cases, etc.</p> - -<p class='c006'>C. Widespread publicity and education with respect to respiratory hygiene, -covering such facts as the dangers from coughing, sneezing, spitting, and the careless -disposal of nasal discharges; the advisability of keeping the fingers and foreign -bodies out of the mouth and nose; the necessity of hand-washing before eating; -<span class='pageno' id='Page_6'>6</span>the dangers from exchanging handkerchiefs; and the advantages of fresh air and -general hygiene. Warnings should be given regarding the danger of the common -cold, and possibly cold should be made reportable so as to permit the sending of -follow up literature to persons suffering from them. The public should be made -acquainted with the danger of possible carriers among both the sick and the well -and the resultant necessity for the exercise of unusual care on the part of everybody -with respect to the dangers of mouth and nasal discharges.</p> - -<p class='c006'>D. Administrative procedures:</p> - -<p class='c006'>1. There should be laws against the use of common cups, and improperly -washed glasses at soda fountains and other public drinking places, which laws -should be enforced.</p> - -<p class='c006'>2. There should be proper ventilation laws, which laws should be enforced.</p> - -<p class='c006'>Since the disease is probably largely a group or crowd problem, the three -following sub-heads are especially important.</p> - -<p class='c006'>3. CLOSING.—Since the spread of influenza is recognized as due to the -transmission of mouth and nasal discharges from persons infected with influenza, -some of whom may be aware of their condition but others unaware of it, to the -mouths and noses of other persons, gatherings of all kinds must be looked upon as -potential agencies for the transmission of the disease. The limitation of gatherings -with respect to size and frequency, and the regulation of the conditions under which -they may be held must be regarded, therefore, as an essential administrative -procedure.</p> - -<p class='c006'>Non-essential gatherings should be prohibited. Necessary gatherings should -be held under such conditions as will insure the greatest possible amount of floor -space to each individual present, and a maximum of fresh air, and precautions -should be taken to prevent unguarded sneezing, coughing, cheering, etc.</p> - -<p class='c006'>Where the necessary activities of the population, such as the performance of -daily work and earning of a living, compel considerable crowding and contact, but -little is gained by closing certain types of meeting places. If, on the other hand, -the community can function without much of contact between individual members -thereof, relatively much is gained by closing or preventing assemblages.</p> - -<p class='c006'><span class='sc'>Schools</span>: As to the closing of schools there are many questions to be -considered.</p> - -<p class='c008'>(a) Theoretically, schools increase the number and degree of contacts -between children. If the schools are closed, many of the contacts which the -children will make are likely to be out of doors. Whether or not closing will -decrease or increase contacts must be determined locally. Obviously, rural and -urban conditions differ radically in this regard.</p> - -<p class='c008'>(b) Are the children in coming to and going from school exposed to inclement -weather or long rides in overcrowded cars?</p> - -<p class='c008'>(c) Is there an adequate nursing and inspection system in the schools?</p> - -<p class='c008'>(d) Is it likely that teachers, physicians and nurses can really identify -and segregate the infected school child before it has an opportunity to make a -number of contacts in halls, yards, rooms, etc.? We suggest that children -<span class='pageno' id='Page_7'>7</span>suspected of having influenza and held in school buildings for inspection -should be provided with and required to wear face masks.</p> - -<p class='c008'>(e) Will the closing of schools release personnel or facilities to aid in -fighting the epidemic?</p> - -<p class='c008'>(f) If schools are kept open, will the absence of many teachers lower -the educational standards?</p> - -<p class='c008'>(g) If a number of pupils stay at home because of illness or fear, will -they not constitute a heavy drag upon their classes when they return?</p> - -<p class='c008'>(h) If schools are closed, is there likely to be an outbreak in any case -when they are reopened?</p> - -<p class='c006'><span class='sc'>Churches</span>: If churches are to remain open, services should be reduced to the -lowest number consistent with the adequate discharge of necessary religious offices, -and such services as are held should be conducted in such a way as to reduce to a -minimum intimacy and frequency of personal contact.</p> - -<p class='c006'><span class='sc'>Theatres</span>: As regards theatres, movies, and meetings for amusement in -general, it seems unwise to rely solely or in great part upon the ejection of careless -coughers. In the first place it is difficult to determine who is a careless cougher, and -after each cough, danger has already resulted. It seems, too, that the closing of -theatres may have as much educational value as their use for direct educational -purposes, etc. Discrimination as to closing among theatres, movies, etc., on the -basis of efficiency of ventilation and general sanitation, may be feasible.</p> - -<p class='c006'><span class='sc'>Saloons, etc.</span>: The closing of saloons and other drinking places should be -decided upon the basis of the probability of spread of the disease through drinking -utensils and the conditions of crowding.</p> - -<p class='c006'><span class='sc'>Dance Halls, etc.</span>: The closing of dance halls, bowling rooms, billiard parlors -and slot-machine parlors, etc., should be made effective in all cases where their -operation causes considerable personal contact and crowding.</p> - -<p class='c006'><span class='sc'>Street cars, etc.</span>: Ventilation and cleanliness should be insisted upon in all -transportation facilities. Over-crowding should be discouraged. A staggering of -opening and closing hours in stores and factories to prevent overcrowding of -transportation facilities may be cautiously experimented with. In small communities -where it is feasible for persons to walk to their work it is better to discontinue -the service of local transportation facilities.</p> - -<p class='c006'><span class='sc'>Funerals</span>: Public funerals and accessory funeral functions should be prohibited, -being unnecessary assemblies in limited quarters, increasing contacts and -possible sources of infection.</p> - -<p class='c006'>4. MASKS.—The wearing of proper masks in a proper manner should be -made compulsory in hospitals and for all who are directly exposed to infection. It -should be made compulsory for barbers, dentists, etc. The evidence before the -committee as to beneficial results consequent upon the enforced wearing of masks -by the entire population at all times was contradictory, and it has not encouraged -the committee to suggest the general adoption of the practice. Persons who desire -to wear masks, however, in their own interest, should be instructed as to how to -make and wear proper masks, and encouraged to do so.</p> - -<p class='c006'><span class='pageno' id='Page_8'>8</span>5. ISOLATION.—The isolation of patients suffering from influenza should be -practised. In cases of unreasonable carelessness, it should be legally enforced most -rigidly.</p> - -<p class='c006'>6. PLACARDING.—In cases of unreasonable carelessness and disregard of -the public interests placarding should be enforced.</p> - -<p class='c006'>7. HOSPITALIZATION.—The theory of complete hospitalization is that, -if all the sick were hospitalized the disease would be controlled. In certain somewhat -small communities where hospitalization of all cases was promptly inaugurated -the disease did come quickly under control. It must be recognized, however, -that unless every infective person can be detected and identified as such and removed -to the hospital before he has infected others, hospitalization cannot be -depended upon to eliminate the disease.</p> - -<p class='c006'>In general, home treatment is to be advocated where medical, nursing and -other necessary facilities are adequate, and where home treatment is not directly -contra-indicated by the danger of infecting others. The hospitalization in any -case, mild or severe, should be undertaken only when facilities for home treatment -are inadequate with respect to medical and nursing care or otherwise. The objection -to routine hospitalization of mild cases lies in the fact that patients not -already suffering from secondary infections may acquire them by exposure to hospital -cases already so infected. The objection to the routine hospitalization of -severe cases lies in the danger to the patient necessarily incident in the transfer -from home to hospital.</p> - -<p class='c006'>8. COUGHING AND SNEEZING.—Laws regulating coughing and sneezing -seem to be desirable for educational and practical results.</p> - -<p class='c006'>9. TERMINAL DISINFECTION.—Terminal disinfection for influenza has -no advantage over cleaning, sunning and airing.</p> - -<p class='c006'>10. ALCOHOL.—The use of alcohol serves no preventive purpose.</p> - -<p class='c006'>11. SPRAYS AND GARGLES.—Sprays and gargles do not protect the nose -and throat from infection, for the following reasons:</p> - -<p class='c008'>(a) So far as the knowledge of the committee extends, no germicide -strong enough to destroy infective organisms can be applied to the nose and -throat without at the same time injuring the mucous membranes.</p> - -<p class='c008'>(b) Irrigation of the nose and throat to accomplish the complete -mechanical removal of the infective organism is impracticable.</p> - -<p class='c008'>(c) Their use tends to remove the protective mucus, to spread the infection -and to increase the liability of actual entrance of the infective -organisms.</p> - -<p class='c008'>(d) Their domestic use is liable to lead in families to a common employment -of the same utensils.</p> - -<p class='c008'>(e) The futility of sprays and gargles has been demonstrated with respect -to certain known organisms such as the diphtheria bacillus and the meningococcus.</p> - -<div class='chapter'> - <span class='pageno' id='Page_9'>9</span> - <h2 class='c007'>MISCELLANEOUS CONSIDERATIONS.</h2> -</div> - -<p class='c005'>1. Colleges, asylums and similar establishments may with advantage enforce -rigid institutional quarantine against the outside world, if they begin in the early -stage of an epidemic, provided they are so located and conducted as to render the -procedure reasonably likely to be effective, even temporarily; for even temporary -success will postpone the appearance of the disease, if it appears at all, to a time -when the patients will be more likely to be able to have adequate medical and -nursing care.</p> - -<p class='c006'>2. The recommended measures for control, even if they do not accomplish the -desired end, should at least be instrumental in distributing the epidemic over a -longer period of time, which in itself is highly desirable.</p> - -<p class='c006'>3. The statistics of the disease and the keeping of proper records are extremely -important. The lack of knowledge regarding innumerable factors in -reference to the disease makes all the more desirable complete case records, etc.</p> - -<p class='c006'>4. The committee wishes to emphasize the need for the complete statistical -study of the collected data on the mortality, morbidity, case fatality, duration, -economic aspects, and therapeutics of the disease. Through the collection of the -facts in a uniform manner, and through the analysis of such tabulated data, -especially mathematical graduation, and testing and study of the figures, important -contributions to the natural history and typical characters of the disease may be -expected. General principles as to the etiology, fatality and practical management -of influenza may follow from the extensive survey of the epidemic in the statistical -laboratory as well as from the intensive bedside observation of single cases of the -disease.</p> - -<p class='c006'>5. The measures recommended are calculated to be effective in the promotion -of respiratory hygiene in general and particularly in the control of pneumonia and -other respiratory infections.</p> - -<div class='chapter'> - <h2 class='c007'>ADMINISTRATIVE MEASURES FOR RELIEF.</h2> -</div> - -<p class='c005'>The committee on administrative measures for relief would submit the following -considerations as constituting a summary of the important measures for meeting -epidemic conditions:</p> - -<h3 class='c009'><i>I. General Rules.</i></h3> - -<p class='c012'>1. Compulsory reporting.</p> - -<p class='c006'>2. Isolation by co-operation and education, to a point where it does not -diminish the willingness of the physician to report.</p> - -<p class='c006'>3. Placarding would seem to be subject to the same limitations as is isolation.</p> - -<p class='c006'>4. The closing of schools, prohibition of funerals, etc., being preventive -measures, are not touched upon in this report, except to mention that the closing of -many agencies will release medical, nursing, and volunteer services for special -influenza work.</p> - -<p class='c006'>5. It may be necessary to grant authority and power to the health authorities -to administer relief.</p> - -<div> - <span class='pageno' id='Page_10'>10</span> - <h3 class='c009'><i>II. Preliminary Measures.</i></h3> -</div> - -<p class='c012'>1. The listing and distribution of resources, including physicians, nurses, -social workers, nurses’ aids, clerks, domestics, laundresses, automobiles, chauffeurs, -mask makers, and volunteers of all kinds.</p> - -<p class='c006'>All available publicity channels should be used to promote volunteer service.</p> - -<p class='c006'>An appeal should be made for voluntary donors of human blood serum from -convalescent influenza patients, to be held in readiness for use in treatment.</p> - -<p class='c006'>2. The centralization of resources, under one control, with central and branch -headquarters, the city being districted for medical, nursing and other work.</p> - -<p class='c006'>The central headquarters should be ordinarily under the supervision of a board -representative of the most important agencies concerned, the board’s work to be -administered through a manager (presumably the health officer) selected for his -fitness.</p> - -<p class='c006'>3. The service should be maintained on a 24–hour basis, and a system of outgoing -and incoming telephone service is essential.</p> - -<p class='c006'>4. The local authorities should get and keep in touch with state and national -agencies.</p> - -<h3 class='c009'><i>III. Current and Continuous Analysis of Case Situation.</i></h3> - -<p class='c012'>1. In the smaller communities a canvass should be made of all physicians, -soliciting information as follows:</p> - - <dl class='dl_1'> - <dt>(a)</dt> - <dd>Number of cases under care. - </dd> - <dt>(b)</dt> - <dd>Number of cases needing hospital treatment. - </dd> - <dt>(c)</dt> - <dd>Number of cases needing home nursing care. - </dd> - <dt>(d)</dt> - <dd>Number of cases requesting medical service but not reached. - </dd> - </dl> - -<p class='c006'>This information will indicate the situation as regarding the need for emergency -nursing and medical service, and should be acquired as fully as possible in -larger communities, through various agencies such as a current lay or police -canvass of homes, etc. The continuous classification of cases according to these -groupings is of practical value.</p> - -<h3 class='c009'><i>IV. Analysis, Augmentation and Organization of Principal Facilities.</i></h3> - -<h4 class='c013'>(A) <i>Field Nursing.</i></h4> - -<p class='c012'>1. Ordinarily nursing facilities utilized in general public health work should -be diverted to meet the epidemic situation, and should be used on a district basis, -with all other available facilities, under one supervision.</p> - -<p class='c006'>2. Nursing assistants, volunteers, etc., should be used wherever possible in -homes and institutions, under expert supervision, after classification and assignment -on a basis of minimum standards as to fitness, and such intensive training in -the care of influenza and pneumonia patients as may be feasible.</p> - -<p class='c006'>3. From the standpoint of the patient, home treatment is to be advocated, -if medical, nursing, disease preventive and other facilities are adequate.</p> - -<p class='c006'>4. Restriction so far as possible through the pressure of public opinion should -be brought against the unnecessary use of private nurses.</p> - -<p class='c006'><span class='pageno' id='Page_11'>11</span>5. Automobile transportation should be provided, and the nursing service -used to encourage isolation and education.</p> - -<p class='c006'>6. Special record forms are essential for this and the medical work, and a -special sub-committee is proposed to meet this problem.</p> - -<p class='c006'>7. Provision as to housing and care should be made for out of town nurses.</p> - -<p class='c006'>8. We recommend further training with reference to influenza for all graduates -of Red Cross Home nursing courses and more extensive use of their services. -This would necessitate frequent and careful registration (names, addresses and -telephone numbers) and further information regarding personal health, age and -ability and willingness to serve.</p> - -<h4 class='c013'>(B) <i>Emergency Medical Service.</i></h4> - -<p class='c012'>1. The medical service should be handled through the central office, the -physicians being responsible to the central office, though perhaps assigned to -district offices.</p> - -<p class='c006'>2. In this emergency service there should be utilized all available physicians -such as school and factory physicians, volunteers, practitioners on a paid basis, -fourth year medical students, etc. This service should cover all calls reported as -unreached by private physicians or received through other channels, and should be -co-ordinated with the special nursing service, being provided with automobile -transportation, machines being hired if necessary.</p> - -<p class='c006'>3. The emergency medical service should be used to select cases needing -hospital care.</p> - -<p class='c006'>4. It may be feasible to institute a central clearing house in certain districts -for private physicians’ calls.</p> - -<p class='c006'>5. An arrangement should be made through the medical licensing board for -granting of temporary permits to practise to reputable physicians from out of the -state, at the request of the Central Influenza Committee.</p> - -<p class='c006'>6. In some localities it may be feasible to district the local practitioner and -to have him meet special calls on a part time basis for adequate compensation.</p> - -<p class='c006'>7. Certain of the relatively non-essential specialties should be discouraged, -and the physician in those specialties urged to volunteer for emergency district -work. This type of service may be operated on a pay or free basis.</p> - -<p class='c006'>8. Presumably some effort should be made, through an authoritative medical -commission, to suggest standard methods of treatment, and wise limitations as to -therapeutic procedure.</p> - -<h4 class='c013'>(C) <i>Hospital Facilities.</i></h4> - -<p class='c012'>1. It is essential that the facilities, if possible, be kept ahead of the demand. -A daily canvass should be made and data collected regarding available beds, -medical and nursing needs, domestics, food, cots, supplies, etc. A regular visit by -an inspector will probably prove more effective than an attempt at telephone -communication.</p> - -<p class='c006'>2. Under most conditions a central clearing house, covering most if not all -of the hospitals, is advisable for the admission of cases. Through this channel the -<span class='pageno' id='Page_12'>12</span>severer cases may receive first consideration. Owing to constant changes in the -hospital bed situation, the daily canvass of facilities may not be wholly depended -upon; on the contrary, it may usually be necessary to telephone the hospital in -order to make sure regarding the admission of a particular case. In any event the -hospitals, if facilities are inadequate, should be impressed with the necessity for -admitting only the most severe or needy cases, pay or free. Special hospital -arrangements should be provided for pregnant women.</p> - -<p class='c006'>3. It is advisable to add wards or tents or new equipment to existing institutions -rather than to establish entirely new emergency hospitals. If practicable, -certain hospitals may be urged to handle influenza cases exclusively.</p> - -<p class='c006'>4. Non-emergency surgical and chronic medical cases amenable to home -treatment should be de-hospitalized.</p> - -<p class='c006'>5. A convalescent home, if adjacent to the hospital, may serve for the care of -mild and convalescent cases, thereby increasing the space in the hospital for acute -cases, obviously involving an increase in the nursing facilities.</p> - -<p class='c006'>6. A canvass of ambulance facilities should be made, ambulances being requisitioned -with payment, or hired by contract, if necessary. Automobiles and motor -trucks should be potentially mobilized for this purpose. Frequently military equipment -may be used if accessible.</p> - -<h3 class='c009'><i>V. Social and Relief Measures.</i></h3> - -<p class='c012'>1. The central office should keep the family advised regarding the patient, -thereby saving telephone calls, trolley fares and worry on the part of the family, -and thereby increasing the willingness for hospitalization.</p> - -<p class='c006'>2. Volunteer workers such as Red Cross volunteers, teachers, relatives, etc., -should be placed in care of families where the responsible members are dead or -hospitalized, this service being under expert social supervision, and the families in -touch with the supply system. Supervision of placed-out children is also necessary.</p> - -<p class='c006'>3. Homes should be investigated before patients are discharged into them, -when destitution or other untoward circumstances are apparent.</p> - -<p class='c006'>4. Precaution should be taken that institutions and families too busy with the -influenza situation to look after their own needs, are covered by the general relief -measures.</p> - -<p class='c006'>5. Ordinary charitable relief should be handled through the routine agencies, -the service co-ordinated with the other epidemiological measures. Churches, -lodges, etc., should be urged to handle their own cases, in order to relieve the pressure -on the central agency. Aid should be immediate, without protracted -investigation.</p> - -<p class='c006'>6. Recreation facilities (motoring, etc.) should be provided for the physicians -and nurses while off duty.</p> - -<h3 class='c009'><i>VI. Food.</i></h3> - -<p class='c012'>1. Available central cooking facilities should be used so far as is necessary, -such as the dietetic equipment in high schools, normal schools, colleges, etc., with -a delivery system to families and institutions in need.</p> - -<p class='c006'><span class='pageno' id='Page_13'>13</span>2. Individual families should be encouraged to cook additional amounts, the -same to be delivered to central diet kitchens for distribution, a standard list of -prepared foods needed being devised and advertised, with recognition of racial -customs and preferences.</p> - -<p class='c006'>3. It may be necessary to establish canteens in sections of the city.</p> - -<h3 class='c009'><i>VII. Laundry.</i></h3> - -<p class='c012'>1. A special collection and distribution system may be essential both for homes -and institutions.</p> - -<p class='c006'>2. It may be necessary to take over a public laundry with compensation, or a -private non-medical institution laundry.</p> - -<h3 class='c009'><i>VIII. Provision for Fatalities.</i></h3> - -<p class='c012'>1. Death reporting should be prompt (24 hours) and a record kept so as to -ensure prompt disposal of bodies.</p> - -<p class='c006'>2. A daily canvass of available coffins should be made, labor assured for construction, -and possibly no coffins sold without the permit of the Influenza Administration -Office.</p> - -<p class='c006'>3. If morgue facilities are inadequate a central place should be provided, with -embalming facilities, for the temporary disposal of bodies.</p> - -<p class='c006'>4. A canvass of hearses should be made and regulations issued prohibiting -unnecessarily long hauls, insisting on maximum capacity loads, etc. A central -control will prevent unnecessary duplication as to routes, etc.</p> - -<p class='c006'>5. A reserve supply of trucks and automobiles should be at hand for use in -various ways in connection with the handling of fatal cases.</p> - -<p class='c006'>6. The number of graves required should be estimated and labor released from -public works or secured through other channels (possibly military) for digging. -Possibly temporary trench interment may be necessary.</p> - -<h3 class='c009'><i>IX. Education, Instruction and Publicity.</i></h3> - -<p class='c012'>Literature and special instructions will be necessary on many phases, including -the following:</p> - -<p class='c006'>1. Instructions to physicians as to reporting, facilities available, district -arrangements, etc.</p> - -<p class='c006'>2. Advice to physicians regarding treatment standards and suggestions.</p> - -<p class='c006'>3. Instructions for families, to be distributed by nurses, physicians, social -workers, druggists, etc., covering the problems of care during the physician’s -absence.</p> - -<p class='c006'>4. Instructions to the public as to where aid may be secured, to be printed in -various languages, and distributed by druggists, displayed in street cars, used in the -press, etc.</p> - -<p class='c006'>5. Instructions for families on “What to do till the doctor comes.”</p> - -<p class='c006'>6. Instructions to physicians, factory managers, school superintendents, etc., -urging the necessity for immediate home and bed treatment at the first sign of -respiratory disease.</p> - -<p class='c006'><span class='pageno' id='Page_14'>14</span>7. Popular literature on the essentials of adequate care, the danger of returning -to work too soon, etc. Popular press space is worth paying for, if it cannot be -secured otherwise.</p> - -<p class='c006'>8. Popular publicity as to legitimate medical, nursing, undertaker, drug, and -other charges, to prevent profiteering.</p> - -<h3 class='c009'><i>X. Miscellaneous.</i></h3> - -<p class='c012'>1. The co-operation of pharmaceutical agencies should be secured to ensure an -adequate supply of drugs and druggists.</p> - -<p class='c006'>2. Influenza victims and their families should have “first call” on fuel -deliveries.</p> - -<p class='c006'>3. While follow up procedures are not legitimately a factor in the epidemic -situation, their consideration is essential to an adequate meeting of the entire -problem. This means adequate provision for medical examination and nursing -care, relief measures, industrial employment problems, the follow up of special -sequelæ such as cardiac affections, tuberculosis, etc.</p> - -<p class='c006'>4. It is finally suggested that Health Department draw up a programme based -on the above outline, holding it in reserve for future use, if not immediately needed, -and modifying the proposal to fit the size and other characteristics of the particular -community.</p> - -<div class='chapter'> - <h2 class='c007'>THE BACTERIOLOGY OF THE 1918 EPIDEMIC OF SO-CALLED INFLUENZA.</h2> -</div> - -<p class='c005'>The epidemic disease known as influenza is believed to be due to an undetermined -organism which causes an infection that lowers the resistance of the body as -a whole, and of the respiratory organs in particular. This allows the invasion of -other pathogenic micro-organisms. The most important complicating infections -are due to the influenza bacilli, different strains of pneumococci and different -varieties of streptococci. Some careful observers regard certain of these organisms -as the primary cause.</p> - -<p class='c006'>In each case, one or several of these micro-organisms may be present. In -different portions of the country the dominating variety of organism has been found -to differ.</p> - -<div class='chapter'> - <h2 class='c007'>VACCINES.</h2> -</div> - -<p class='c005'>Assuming that the cause of the epidemic is an unknown virus, it does not seem -possible at present to prevent the primary disease by vaccination with known -organisms. Against the secondary infections, there would seem to be a theoretical -basis for the use of vaccines, and especially for the use of vaccines prepared from -organisms responsible for complications which may differ in various localities at -various times. This variable bacterial flora may militate against the practical -application of vaccination on a large scale, because it would seem to require frequently -repeated vaccinations with the flora that may be met with. It is impossible -at present to evaluate the reports from the use of these vaccines adjusted to meet -<span class='pageno' id='Page_15'>15</span>local conditions. More data obtained under carefully controlled conditions are -needed.</p> - -<p class='c006'>Stock vaccines made from the influenza bacillus alone or from other bacteria, -have been used to considerable extent. The injections of stock vaccines have seemed -to mitigate to some degree some outbreaks of influenza and also the severity of the -complicating infections; but in those instances in which the results of the use of -vaccine have been controlled, no appreciable results have been obtained. The fact -that the vaccine is usually employed after the epidemic has broken out and is -perhaps on a decline, and the fact that an unknown number of people have been -exposed, make it very difficult to draw conclusions as to its efficacy.</p> - -<div class='chapter'> - <h2 class='c007'>RECOMMENDATIONS.</h2> -</div> - -<p class='c005'>Your committee recommends that until such time as the efficacy, or the lack -of efficacy, of prophylactic vaccination against influenza is established, vaccine if -used, should be employed in a controlled manner, under conditions that will allow a -fair comparison of the number of cases and of deaths among the vaccinated and -non-vaccinated groups. Particular attention should be directed to securing data as -to the period in the epidemic at which vaccinated and non-vaccinated persons -developed the disease.</p> - -<p class='c006'>Your committee is of the opinion that the indiscriminate use of stock vaccines -against influenza and influenza and pneumonia cannot be recommended.</p> - -<p class='c006'>Nothing in these recommendations should be interpreted as discouraging the -use of a pneumococcus stock vaccine against lobar pneumonia.</p> - -<p class='c006'>This epidemic emphasizes the importance of properly equipped laboratories.</p> - -<div class='chapter'> - <h2 class='c007'>HISTORY AND STATISTICS OF THE EPIDEMIC.</h2> -</div> - -<p class='c005'>Your sub-committee wishes to say that in view of the fact that the historical -and other data of the epidemic are still in process of collection, no positive statement -can be made at the present time on the precise incidence of the disease in -the American population. On the basis of the best data available your sub-committee -estimates that there were not less than 400,000 deaths from the disease in -the United States during the months of September, October and November, 1918. -The major portion of this mortality occurred at ages 20–40, when human life is -of the highest economic importance. We would suggest that this sub-committee -be authorized to co-operate with the special committee on statistical study of the -epidemic of the section on Vital Statistics of this Association, and that the data -collected through that latter special committee be reported through the sub-committee -on history and statistics of the epidemic to the general reference committee -on the influenza epidemic. Standard forms for purposes of statistical tabulation, -analysis and graphic presentation will be submitted in a supplementary report -at an early date.</p> - -<div class='chapter'> - <span class='pageno' id='Page_16'>16</span> - <h2 class='c007'>SUGGESTIONS.</h2> -</div> - -<p class='c005'>In view of the probability of recurrences of the disease from time to time -during the coming year, health departments are advised to be ready in advance with -plans for prevention, which plans shall embody the framework of necessary -measures and as much detail as possible. Laws plainly necessary should be enacted -and rules passed now. Emergency funds should be held in reserve or placed in -special appropriations, which appropriations can be quickly made available for -influenza prevention work.</p> - -<p class='c006'>The probability that as an after effect of the influenza epidemic there will be -an unusually high pneumonia rate for several years should be taken into consideration.</p> - -<p class='c006'>Of measures for the control of the disease, bacteriologic studies as to the -nature of the organisms causing the primary infection and as to bacteria associations, -new and improved procedures leading to the production and use of effective -vaccines and curative sera, and the fresh air treatment of the infected, appear to -offer most promise.</p> - -<div class='pbb'> - <hr class='pb c004' /> -</div> -<div class='tnotes'> - -<div class='chapter'> - <h2 class='c007'>TRANSCRIBER’S NOTES</h2> -</div> - <ol class='ol_1 c003'> - <li>Silently corrected typographical errors and variations in spelling. - - </li> - <li>Retained anachronistic, non-standard, and uncertain spellings as printed. - </li> - </ol> - -</div> - - - - - - - - -<pre> - - - - - -End of Project Gutenberg's Influenza, by Provincial Board of Health Ontario - -*** END OF THIS PROJECT GUTENBERG EBOOK INFLUENZA *** - -***** This file should be named 60087-h.htm or 60087-h.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/6/0/0/8/60087/ - -Produced by Richard Tonsing and the Online Distributed -Proofreading Team at http://www.pgdp.net (This file was -produced from images generously made available by The -Internet Archive) - - -Updated editions will replace the previous one--the old editions -will be renamed. - -Creating the works from public domain print editions means that no -one owns a United States copyright in these works, so the Foundation -(and you!) can copy and distribute it in the United States without -permission and without paying copyright royalties. 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