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diff --git a/old/60087-h/60087-h.htm b/old/60087-h/60087-h.htm deleted file mode 100644 index 0ec09aa..0000000 --- a/old/60087-h/60087-h.htm +++ /dev/null @@ -1,1404 +0,0 @@ -<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN" - "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd"> -<html xmlns="http://www.w3.org/1999/xhtml" xml:lang="en" lang="en"> - <head> - <meta http-equiv="Content-Type" content="text/html;charset=UTF-8" /> - <title>The Project Gutenberg eBook of Influenza, by Ontario Provincial Board of Health</title> - <link rel="coverpage" href="images/cover.jpg" /> - <style type="text/css"> - body { margin-left: 8%; margin-right: 10%; } - h1 { text-align: center; font-weight: bold; font-size: xx-large; } - h2 { text-align: center; font-weight: bold; font-size: x-large; } - h3 { text-align: center; font-weight: bold; font-size: large; } - h4 { text-align: center; font-weight: bold; font-size: 1em; } - .pageno { right: 1%; font-size: x-small; background-color: inherit; color: silver; - text-indent: 0em; text-align: right; position: absolute; - border: thin solid silver; padding: .1em .2em; font-style: normal; - font-variant: normal; font-weight: normal; text-decoration: none; } - p { text-indent: 0; margin-top: 0.5em; margin-bottom: 0.5em; text-align: justify; } - .sc { font-variant: small-caps; } - .large { font-size: large; } - .xlarge { font-size: x-large; } - .under { text-decoration: underline; } - .dl_1 dd { text-align: left; padding-top: .5em; margin-left: 2.7em; - text-indent: -1em; } - .dl_1 dt { float: left; clear: left; text-align: left; width: 1.5em; - padding-top: .5em; padding-right: .5em; } - .ol_1 li {padding-left: 1em; text-indent: -1em; } - @media handheld { .dl_1 dt { float: left; clear: left; text-align: left; - width: 1.5em; padding-top: .5em; padding-right: .5em; } } - dl.dl_1 { margin-top: .5em; margin-bottom: .5em; } - ol.ol_1 {padding-left: 0; margin-left: 2.78%; margin-top: .5em; - margin-bottom: .5em; list-style-type: decimal; } - div.pbb { page-break-before: always; } - hr.pb { border: none; border-bottom: thin solid; margin-bottom: 1em; } - @media handheld { hr.pb { display: none; } } - .chapter { clear: both; page-break-before: always; } - .figcenter { clear: both; max-width: 100%; margin: 2em auto; text-align: center; } - div.figcenter p { text-align: center; text-indent: 0; } - .figcenter img { max-width: 100%; height: auto; } - .id001 { width:10%; } - @media handheld { .id001 { margin-left:45%; width:10%; } } - .ic001 { width:100%; } - .ig001 { width:100%; } - .nf-center { text-align: center; } - .nf-center-c0 { text-align: left; margin: 0.5em 0; } - .c000 { margin-top: 0.5em; margin-bottom: 0.5em; } - .c001 { margin-top: 4em; } - .c002 { page-break-before: always; margin-top: 4em; } - .c003 { margin-top: 2em; } - .c004 { margin-top: 1em; } - .c005 { margin-top: 2em; text-indent: 1em; margin-bottom: 0.25em; } - .c006 { text-indent: 1em; margin-top: 0.25em; margin-bottom: 0.25em; } - .c007 { page-break-before:auto; margin-top: 4em; } - .c008 { margin-left: 2.78%; text-indent: 1em; margin-top: 0.25em; - margin-bottom: 0.25em; } - .c009 { text-align: left; page-break-before: always; margin-top: 2em; } - .c010 { margin-left: 2.78%; margin-top: 1em; text-indent: 1em; - margin-bottom: 0.25em; } - .c011 { margin-left: 2.78%; text-indent: 0; margin-top: 0.25em; - margin-bottom: 0.25em; } - .c012 { margin-top: 1em; text-indent: 1em; margin-bottom: 0.25em; } - .c013 { text-align: left; page-break-before: auto; margin-top: 2em; } - div.tnotes { padding-left:1em;padding-right:1em;background-color:#E3E4FA; - border:1px solid silver; margin:2em 10% 0 10%; font-family: Georgia, serif; - } - .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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