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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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