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 Health IT as a Tool
for Prevention in
Public Health Policies
Divya Srinivasan Sridhar
 Health IT as a Tool
for Prevention in
Public Health Policies
 Health IT as a Tool
for Prevention in
Public Health Policies

Divya Srinivasan Sridhar

CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742

© 2014 by Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, an Informa business

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Version Date: 20130815

International Standard Book Number-13: 978-1-4822-1475-8 (eBook - PDF)

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 This book is dedicated to the two most important
men in my life—my brother, Aditya Srinivasan, and
my husband, Badri Sridhar. They have provided me
with the gifts of love and laughter, more so than any
others in my life. I could see the light at the end of the
tunnel when writing this book because of them.

© 2010 Taylor & Francis Group, LLC

Contents

Preface......................................................................... xiii
About the Author........................................................ xvii

Section I  INTRODUCTION
1 Theoretical Underpinnings: Comparing
the PPACA and HITECH Acts...................................3
Introduction.......................................................................... 3
Theoretical Perspectives...................................................... 4
Social Cognitive Theory............................................... 7
Measuring Progress and Outcomes............................. 9
Conclusion...........................................................................10
References...........................................................................12

Section II  GOVERNMENT AND TECHNOLOGY POLICIES

2 Impact of E-Government on Electronic Health
Literacy...................................................................15
Introduction.........................................................................16
Theory.................................................................................19
Sources of E-Health Initiatives by E-Government.............21
Mobile Health Initiatives.............................................21
Initiatives to Reduce the Digital Divide......................22
Legislation Impacting E-Health Literacy.............................23
Key Legislation for Furthering E-Health.....................24

© 2010 Taylor & Francis Group, LLC vii

viii ◾ Contents

Health Insurance Exchanges..............................................26

RHIOs..................................................................................27
Web Design and E-Health................................................. 28
Non-Health-Related Legislation Furthering
E-Health....................................................................30
Policy Analysis: Summary of Importance
of E-Government on E-Health Literacy..............................32
Trust in Information Sources and Impacts
on E-Health Literacy Outcomes..................................32
Methods...............................................................................34
New Contribution to the Field: New
E-Government Term....................................................34
Interpretation and Results...................................................40
Policy Recommendations and Conclusions........................41
References.......................................................................... 44

3 Financial, Social, and Environmental Impact

of Government HIT Adoption Policies....................47
Assessment of the Barriers to Health Information
Technology (HIT) Adoption across Organizations
and the U.S. Policy Solutions............................................. 48
Organizational Variation in EMR Adoption........................50
Barriers to EMR Adoption...................................................53
Economic Costs of EMR Adoption.............................54
Economic Policy Strategies to Help
Organizations with Slow Rates of Adoption.......56
Social Barriers to Technology Adoption.....................57
Social Policies to Help Organizations That
Are Unable to Adopt EMRs.................................59
Environmental Barriers to Technology Adoption......61
Environmental Policy Strategies to Help
Organizations with Slow Rates of Adoption.......63
Conclusion.......................................................................... 64
References...........................................................................65
© 2010 Taylor & Francis Group, LLC
 Contents ◾ ix

Section III 
INDIVIDUALIZED TECHNOLOGICAL
PREVENTION STRATEGIES FOR
CHRONIC CONDITIONS
4 Self-Management Technologies and Type 2
Diabetes..................................................................71
The Effects of Self-Management Technologies
on Type 2 Diabetes Patients...............................................73
Purpose........................................................................73
Introduction and Background.....................................73
Policy Relevance..................................................76
Theoretical Backing............................................ 77
Web-Based Technologies....................................81
Mobile and Telephone Interventions................. 84
Video Games.......................................................85
Discussion................................................................... 86
Conclusion...........................................................................89
Limitation of the Chapter and Possible Sources of Bias......92
References...........................................................................93
5 Individualized Prevention Solutions
to Childhood Obesity..............................................95
Underlying Causes and Consequences of Childhood
Obesity................................................................................95
Consequences of Childhood Obesity.................................97
National Policy Solutions................................................... 98
State Policy Solutions........................................................100
Local Policy Solutions....................................................... 101
Environmental Policies..............................................102
Physicians and Health Providers.......................103
Media Impacts...................................................104
Economic Policies......................................................105
Political Community Relationships/Partnerships......108
Child Care Policies............................................................ 111
Technological Policies and Social Media.................. 112
Political Impacts........................................................ 114
Conclusion......................................................................... 115
© 2010 Taylor & Francis Group, LLC
x ◾ Contents

References......................................................................... 116
Suggested Readings...........................................................120

Section IV 
NATIONAL AND INTERNATIONAL
IMPACTS OF HIT ON THE COMMUNITY
6 Health Information Technology in Community
Health Centers......................................................125
The Formation of Community Health Centers (CHCs)......126
Theory for the Design......................................................129
Literature Review..............................................................136
Research Design................................................................142
Research Experiment 1: Randomized
Experimental Design.................................................143
Research Experiment 2: The Survey Design............148
Conclusion......................................................................... 154
References......................................................................... 157
7 Small-Practice Physicians and HIT....................... 159
Why HIT? What Is It and How Can It Help Small-
Practice Physicians?...........................................................160
Physicians and Organizational Leadership.......................163
Literature and Theories Relating to Technology
Diffusion............................................................................165
Technology Diffusion................................................166
Customer Service and Quality..................................166
Barriers to Adoption.................................................. 167
Looking to the Future: New Research..............................169
How Do Small Practices Deal with Change
and Regulation?.........................................................169
Methods............................................................. 170
Hypotheses........................................................ 171
Survey Findings................................................. 171
Results and Analysis.......................................... 178
Conclusion and Recommendations..........................180
References.........................................................................183
© 2010 Taylor & Francis Group, LLC
 Contents ◾ xi

8 The Micro, Meso, and Macro Perspectives of

HIT Adoption........................................................185
Introduction.......................................................................186
Macro-Level Policies and Considerations.........................187
Meso-Level Challenges to Electronic Medical Record
(EMR) Adoption................................................................ 193
Micro-Level Challenges to EMR Adoption.......................198
Conclusion.........................................................................204
References.........................................................................205
9 Geographic Disparities in Healthcare..................209
Geographic Disparities in Health Resources.................... 211
Geographic Disparities in Healthcare Professionals........ 215
Policy Solutions to Geographic Maldistribution
of Resources and Care...................................................... 217
Solutions to the Shortage of Health Resources
and Services: Federally Qualified Health Centers
(FQHCs) and Community Health Centers (CHCs)....218
Solutions to the Shortage of Health Resources
and Services: Telemedicine Resources......................220
Solutions to the Shortage of Health Resources
and Services: Concierge Medicine............................222
Conclusion.........................................................................224
References.........................................................................225
10 International Comparisons: Differences in U.K.
and U.S. Preventive Health...................................229
Applying the Reforms of the U.K. NHS to the U.S.
Health System: A Comparative Perspective.....................230
Introduction...............................................................230
General Differences: The U.K. versus the U.S.
Health System....................................................................231
Reforms to the U.K. Health System in the Early 2000s.....234
The U.K.’s QOF System.............................................235
Criticisms of the U.K. Health Reforms and
the QOF.....................................................................237
© 2010 Taylor & Francis Group, LLC
xii ◾ Contents

Comparing and Applying the U.K. to the U.S.

Health System....................................................................238
Comparisons and Additions of the U.K. QOF
to Concierge Medicine......................................................243
Conclusion.........................................................................246
References.........................................................................248
11 Conclusion............................................................ 251
Putting It All Together...................................................... 251

© 2010 Taylor & Francis Group, LLC

Preface

The PPACA and a New Focus on Prevention

The passing in 2010 of the Patient Protection and Affordable
Care Act (PPACA) has produced a significant set of objectives
for the United States and, indirectly, for the entire world. The
PPACA works to produce solutions to a number of the coun-
try’s old health system problems. More importantly, the solu-
tions will be seen as most effective in the long term, once they
are implemented in the short term.
Table P.1 starts off by detailing some of the major problems
the U.S. has faced with its healthcare system (left column)
and then suggests the current federal efforts to solve these
problems (center column), followed by new solutions that are
proposed (right column). Each of the chapters of this book
represents a particular technological solution in which the U.S.
is investing time, resources, interest, and energy.
As can be seen, the chapters that follow are grouped by
theme, impact on society, and stakeholder category. Chapter
1 provides a basic theoretical foundation about the PPACA
(2009) and the HITECH (Health Information Technology
for Economic and Clinical Health) Act (2009) and analyzes
their effect on the future of the U.S., providing descriptions
of comparisons across these pieces of legislation. Chapters
2 and 3 focus on health information technology (HIT), sug-
gesting the foundation for its uses, its value, and the neces-
sity for an electronic framework in the U.S. Chapters 4 and 5

© 2010 Taylor & Francis Group, LLC xiii

xiv ◾ Preface

Table I.1 Problems and Technological Solutions

Problem Faced by Chapter That Explains
the United States Current Solutions a Potential Solution
A detached Electronic government Chapter 2: A new
health system collaboration networks electronic
with lack of Plain Writing Act government structure
coordination and Chapter 3: HIT (health
connectivity; not Electronic personal
health records information
enough outreach technology) and
in improving “Meaningful Use,”
health literacy policies, as well as
sociocultural and
environmental
impacts of HIT
Changing Mobile health apps Chapter 4: Individual
individual Video games for self-management
attitudes toward health improvement technologies and
health and diabetes
prevention; Personal health
records/patient Chapter 5: Chronic
focusing on conditions of
technology that controlled health
records (PCHRs) childhood obesity,
can help one cardiovascular
understand him/ Michelle Obama’s disease, and others
herself “Let’s Move”
Campaign
Crowdsourcing
Telemedicine
Government- HIT at CHCs Chapter 6: Federal
funded (composite health efforts for HIT at
prevention care systems) community health
initiatives Telemedicine near centers (CHCs)
disparate regions
Regional extension
centers (RECs)
(Continued)

© 2010 Taylor & Francis Group, LLC

 Preface ◾ xv

Table I.1 Problems and Technological Solutions (Continued)

Problem Faced by Chapter That Explains
the United States Current Solutions a Potential Solution
Struggles with HIT usage at small Chapter 7: Physicians
health practices—usefulness and HIT
professionals and opinions Chapter 8: Moving
using HIT forward—big data at
the micro, meso, and
macro levels
Cloud-based solutions
Community Telemedicine Chapter 9: Geographic
involvement: Regional health disparities
How to make information Chapter 10:
prevention a organizations (RHIOs) International
community focus comparisons between
Regional extension
centers (RECs) the U.S. and the U.K.

Overview: How All of the above, and Chapter 11:

can these more Conclusion
solutions be put
together to make
prevention a
possibility?

take an individualized approach, asking what people can do

to improve their own chances at preventing health concerns
before problems arise, and producing a healthy lifestyle by
supplementing health information technologies of varying
kinds, including (though not limited to) mobile health apps,
video games, self-management technologies, crowdsourc-
ing, and other types of electronic health (e-health). Chapters
6 and 7 analyze what the government has done to supple-
ment HIT efforts at various provider settings, including com-
munity health centers that affect low-income populations and
small practices. The chapters include a pilot study/survey on

© 2010 Taylor & Francis Group, LLC

xvi ◾ Preface

physicians and their viewpoints on HIT. Next, Chapters 8 and

9 discuss the effects of geographic disparities and HIT at the
meso, macro, and micro levels of society. Finally, Chapter 10
provides a comparative perspective, suggesting a comparison
between the United States and the United Kingdom. Chapter
11 is a summary of the book, with hints about the direction
that the U.S. should take toward cloud-based solutions to its
electronic health infrastructure.

© 2010 Taylor & Francis Group, LLC

About the Author

Divya Srinivasan Sridhar works in the field of public pol-

icy. She has developed her knowledge and experience at a
number of public policy organizations including the Institute
for Women’s Policy Research (IWPR), National Housing Trust
(NHT), Healthcare Information Management Systems Society
(HIMSS), Verité Healthcare Consulting (VHC), and more. She
has delved into a variety of public policy issues during her
internships and graduate programs, and has published and
written papers on electronic government, social policy, and
healthcare, including health reform, healthcare IT, and health
informatics. She completed her bachelor’s degree in finance
at Texas A&M University, her master’s degree in public policy
from the University of Texas, Dallas, specializing in social
policy/health policy research, and is now working on her
PhD in public policy at George Mason University in Arlington,
Virginia. Srinivasan is the author of Impact of Healthcare
Informatics on Quality of Patient Care and Health Services
(CRC Press, 2013).

© 2010 Taylor & Francis Group, LLC xvii

INTRODUCTION I

© 2010 Taylor & Francis Group, LLC

Chapter 1

Theoretical
Underpinnings:
Comparing the PPACA
and HITECH Acts

Introduction
This chapter focuses on the PPACA (Patient Protection and
Affordable Care Act) and the HITECH (Health Information
Technology for Economic and Clinical Health) Act, which are
seen as separate entities. The author looks at a theoretical
perspective on how these pieces of legislation are affecting the
community, and how focused they are on prevention in public
health. Also analyzed are the main players in public health,
which will focus on government, the individual, the commu-
nity, and physicians/health providers. This will lay the foun-
dation for the rest of the chapters in this book, which cover
these specific set of stakeholders and their importance in mak-
ing prevention their purpose, and improved public health out-
comes a reality. Not only can these stakeholders use the new
health reform as a major pillar for change, but they also can

© 2010 Taylor & Francis Group, LLC 3

4 ◾ Health IT as a Tool for Prevention in Public Health Policies

use health information technologies as a tool for improving

health, which is why these two laws and concepts should be
analyzed together. This chapter’s perspective is fresh, because
most researchers look at what each individual legislation offers
and the objectives of the legislation, rather than the bigger pic-
ture of what the legislation is proposing and whether the com-
munity is able to achieve perceived benefits. The author ties
the two pieces of legislation together and analyzes similarities
and differences in producing community well-being.

Theoretical Perspectives
There are a number of theories that actually pertain to both
the PPACA and the HITECH Act. These theories are a part of
the Venn diagram in Figure 1.1. The way that the theories are
applied and utilized by the community provide the differences
in these pieces of legislation. The author begins by discussing
the theories that may be used to describe both acts, and then
discusses how the applications may differ when implementing
and assessing the use and impact of each piece of legislation.
Health behavior theory, as suggested by Noar, Chabot, and
Zimmerman (2008) as well as others, is defined as a psycho-
logical mindset of individuals to improve their own healthcare
situation when provided the tools and resources to empower
themselves. Global health standards and ideals as well as mul-
tiple aspects of health education and improvement (“multiples
behaviors”) can impact health choices and principles (Noar et
al., 2008). Potential impacts from such a mindset are part of
a smaller theory known as SCT, which may include the per-
ceived susceptibility, perceived severity, perceived benefits,
perceived barriers, cues to action, self-efficacy, and more, as
discussed by Glanz et al., (2002). Because of the wider impact
of such theory, it pertains to the PPACA and the broad ranging
effects of the PPACA on the community. The health behavior
© 2010 Taylor & Francis Group, LLC
 HITECH ACT PPACA
2008 2009

Application of Theories Differs as

Application of Theories Differs as
Suggested Below
Suggested Below
Overlapping
Self-efficacy & Cognitive Theories
Self-efficacy & Cognitive Theories Theories Traditional literacy, Health literacy
media literacy, computer literacy, scientific
Norman (2006)
literacy, and information literacy
Norman (2006)
-Health
Iron Triangle in healthcare: Access, Quality,
Behavior & Cost of programs, resources
Iron Triangle in healthcare informatics (Used by many reports, no particular source)

© 2010 Taylor & Francis Group, LLC

Access, Quality, Cost of technology and impact
on markets;
Supply/Demand in markets: governments,
providers, vendors, individuals
Primary Care Practice Redesign:
The Chronic Care Model
Technological components of the model
require funding, investment of time,
money, interests, political power, and other
sources of capital
Self-efficacy
Health Behavior Theory: individual and
theory community interest in public health programs
(Glanz, Rimer, and Su, 2005)
-Iron Triangle
Primary Care Practice Redesign:
-PCMH Model The Chronic Care Model
(Wagner and Michael von Korff) ;
IHI’s Idealized Design of Clinical
Office Practices initiative (John
Wasson and Chick Kilo); and Clinical
Microsystems (Gene Nelson)
Theoretical Underpinnings
◾

Figure 1.1 Venn diagram: Theoretical overlap.

5
6 ◾ Health IT as a Tool for Prevention in Public Health Policies

theory encompasses social cognitive theory (SCT), which

affects the HITECH Act of 2008.
The SCT suggests that individuals can impact their own
health behaviors and goals, with a focus on literacy as the way
to enrich individuals’ health behaviors. To apply SCT to the
HITECH Act, many of the goals of the HITECH Act include
empowering individuals with new tools and technologies to
provide individualized, personalized solutions to improved
healthcare and introducing networks of connectivity between
providers, patients/consumers, and other third party organi-
zations. The SCT suggests a number of literacy types, with a
focus on health, media, information, and computer literacy as
opposed to the traditional literacy focus. The development of
society through other types of technological literacy in relation
to health may be where the HITECH differs from the PPACA.
The HITECH Act distinctly focuses on improving individuals’
computer literacy through direct and indirect initiatives. These
literacy types are discussed in Chapter 2 when applied to the
role of electronic government.
When applied to the PPACA, the theories may have differing
outcomes than when applied to the HITECH Act.
Individuals may positively use PPACA to gain health insur-
ance (especially those in a position to have newly acquired
health insurance through expanded Medicaid coverage or
subsidies on their health insurance plan), use health literacy
tools provided by the government, and use preventative care
strategies that are being pushed through PPACA initiatives
(obesity prevention, healthier lifestyles, increase in the pri-
mary care physician workforce, and others). At the same time,
some individuals may free-ride on the benefits they receive
through PPACA, an option to use their newly acquired health
insurance to care even less about their healthcare because it
is being paid through taxpayer funds. The community has
the option to not make the most out of many of the PPACA
provisions that could actually benefit it. In this sense, the
self-efficacy theory can really impact those who want to be
© 2010 Taylor & Francis Group, LLC
 Theoretical Underpinnings ◾ 7

impacted. Small businesses are struggling to keep afloat with

the economy and the rules that now require employers to
provide employee health insurance coverage. The health insur-
ance exchange may be a way to provide new government-
sponsored health coverage that can compete with private
insurance companies for covering individuals. Policies against
cherry-picking individuals with co-morbidities (known as
“community rating” and “guaranteed issue” policies in PPACA)
may have substantial impact on those who learn more about
how these policies can affect them. Youth are covered under
health insurance from family and guardians until the age of
26. As can be seen, the PPACA provides a set of mixed results
across the community, and continues to be debated concern-
ing its effectiveness. Much of the cost and quality effectiveness
can differ based on the cognitive theory and how individuals
and the community utilize the PPACA. Next is a discussion on
the effects of HITECH Act using social cognitive theory (SCT).

Social Cognitive Theory

The social cognitive theory can also be applied to the
HITECH Act, in an applied sense, compared to the PPACA.
The HITECH Act provides many provisions that make avail-
able grants, funding, and initiatives for easing technology
into the provider and community settings. Yet, the impact of
electronic health (e-health) is difficult to understand until it
is fully utilized by the community. As will be discussed in
Chapter 2, electronic government initiatives may help society
learn more about their own health needs and in tracking their
health behavior as well as improving the quality of their health
needs. On the other hand, if providers or individuals misuse
or hurt their own health outcomes by utilizing technologies,
the impact is not only negative but difficult to reverse after
creating a large platform for health technologies. For example,
the health information exchange that involves the coordination
and collaboration services for data exchange across provider
© 2010 Taylor & Francis Group, LLC
8 ◾ Health IT as a Tool for Prevention in Public Health Policies

settings, including hospitals, practices, and healthcare orga-

nizations (as well as business entities and other third parties
that may be involved), could work to benefit providers, as well
as patients who are linked to these providers. At the same
time, the health information exchange may leave out many
practices that cannot afford to participate (discussed in later
chapters) as well as those practices or parts of the commu-
nity who intentionally choose not to participate. The Health
Insurance Portability and Accountability Act (HIPAA) can have
positive or negative impacts on HITECH and the community,
based on how cognitively useful the community finds HIPAA
and whether or not the community is for or against changes
to their HIPAA rights. Many of the HITECH provisions are
closely entangled with the individual lifestyles of patients and
consumers, and whether or not they are interested in their
own healthcare and health outcomes. So again, similar to the
PPACA, the benefits of HITECH may only be seen based on
how much individuals are involved in their own self-efficacy.
The difference in application of the SCT and health behav-
iors theory may be in the degree and level to which they
impact society. This stems from the health behavior theory
that suggests that individuals only use tools to the extent that
they believe the tools will produce effectiveness and effi-
ciency in their lives, which is based on their level of literacy
on the issues. SCT is greatly affected by health behavior theory
because individuals take steps and actions to make differences
in their health behaviors based on their own health literacy
and how easily affected this knowledge is. While PPACA can
affect traditional literacy, the HITECH Act may affect electronic
and computer literacy skills that, in the big picture, will affect
utilization of various health tools to impact health outcomes.
Providing new means for individuals to access electronic health
through pilot projects and electronic government is a step
forward for the HITECH Act; if used correctly, it can improve
traditional health literacy and create a strong foundation, in
collaboration with the PPACA. Equipping the community with
© 2010 Taylor & Francis Group, LLC
 Theoretical Underpinnings ◾ 9

tools and legislation that suggests changes in community

health is the first step toward progress. At the same time, the
way that progress and outcomes are measured differs across
the two pieces of legislation.

Measuring Progress and Outcomes

The PPACA has been known to be measured through the
“iron triangle” of healthcare, including the dimensions of cost,
access, and quality. These three outcomes must be carefully
juggled in order to produce a health system that is not too
heavily focused on cost effectiveness while producing prob-
lems with quality and vice versa. Similarly, the iron triangle
can be used to measure the HITECH Act outcomes, as the
costs of technology can affect markets, and access to technol-
ogy is affected by the digital divide (the gap between those
with access to digital and IT and those without which is the
result of socioeconomic barriers in society.
Both the HITECH Act and PPACA are rooted in yet another
theory, known as the Chronic Care Model, which provides for
integration of technology across healthcare settings between
providers, patients, and the community. This theory illus-
trates the application of the health behavior theory and SCT
in the real world, such that those in the community can see
practical outcomes in their lives. The Chronic Care Model has
four major components: the community, the health system,
informed patients and families, and prepared, proactive teams.
The solidarity of the four components allows for a stronger
healthcare structure in the United States overall, if followed
correctly. The Chronic Care Model also can address many of
the disparities from geography, demographics, and the digital
divide, through new creative individualized and team-based
solutions. Following the Chronic Care Model is the Patient-
Centered Medical Home (PCMH) movement, a practice rede-
sign movement to restructure the objectives of the healthcare
provision, specifically at health provider settings. While the
© 2010 Taylor & Francis Group, LLC
10 ◾ Health IT as a Tool for Prevention in Public Health Policies

overall idea is the same, the specific objectives may differ

between HITECH and PPACA. The HITECH Act would advo-
cate health information technologies in the practice, while
PPACA would recommend patient-centered objectives in col-
laboration with HIT. (The Chronic Care Model is discussed in
greater detail in Chapter 4.)
The diagram in Figure 1.1 illustrates, in a concise manner,
many of the theories discussed above. Previously discussed
were some of the theories to better understand the need for
the PPACA and HITECH Act, and potential impacts from the
two pieces of legislation. Figure 1.2 compares and contrasts
health objectives of the two legislations.
A number of the objectives of the PPACA and HITECH
Act are similar—the goal of the iron triangle outcomes of
cost, quality care, efficiency, and more objective health mea-
sures and measurements of performance are present across
both types of legislation. Priorities of the PPACA have been
expanding access to health insurance with a serious amount
of government expansion on many of the health decisions
that were previously completed privately at the individual or
health provider level. On the other hand, the HITECH Act
introduces some new privacy rights for individuals (including
reforms to HIPAA), as well as grants and expansion of tech-
nological infrastructure across health providers. Here, there
is some level of government expansion on decision making
and government access to health information that can make
conservatives uncomfortable. Yet, the HITECH Act has been
deemed bipartisan, though the PPACA has been accepted as
left wing.

Conclusion
This chapter highlighted some of the major theories and objec-
tives of the PPACA and HITECH Act to provide a foundation
for the next set of chapters that discuss the goal of prevention
© 2010 Taylor & Francis Group, LLC
Another random document with
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 Spread of Influenza in 1889–90.

Month. 1889–90.
First (October) St. Petersburg, Moscow, Courland, Livonia, Finland.
Second Berlin, Paris, Vienna, Sweden, Denmark.
Third London, Holland, Belgium, Balkan States, North America.
Fourth Capetown, Egypt, Honolulu, Mexico, Japan, Hong Kong.
Fifth San Francisco, Buenos Ayres, India, Sierra Leone, Scilly Islands.
Sixth Chili, Kamerun, Zanzibar, Basutoland, Tasmania.
Seventh British Bechuanaland, Barbados.
Eighth Gold Cost, Natal.
Ninth Trinidad.
Tenth Iceland, Madagascar, China, Senegal.
Eleventh Kashmir, Katunga.

Between the years 1889 and 1893 according to Leichtenstern there was no period
altogether free from influenza. Here and there individual cases or small epidemics
sharply localized were observed. In 1893 another epidemic appeared in many places and
became quite widespread. There was not, according to this author, the definite
geographic progression that had been observed in 1889. This was but a recrudescence, a
lighting up from endemic foci remaining after the first wide spread. In the first half of
1893 there was a light spring epidemic, and in November of the same year a larger
epidemic swept over the whole of Europe. The height of the latter was reached chiefly in
December.
The influenza incidence subsequent to 1893 will be discussed later.
 TABLE I.
Influenza epidemics previous to 1889.
Date. General Site of origin. Direction of Localities Rapidity of
features. spread. affected. spread.
1173 Rather meagre Unknown. Described in Not known.
description. Italy, Germany,
England.
1239 Described by Described in Invaded all of
1311 Zeviani. France. France.
Records not
definite. Not
generally
accepted.
1323 Mentioned by
Hirsch, Gluge
and Zeviani.
Most believes
it was a
typhoid
epidemic.
1327 Mentioned by Described in
Zeviani, Italy.
Hirsch and
Gluge. Rather
doubtful.
1358 Described by Savoy, Germany,
Zeviani. Not France,
generally Catalonia.
accepted.
1387 (Zeviani, Italy. Italy, France,
Schweich, Strasbourg,
Gluge, Hirsch Southern
and Germany.
Ripperger.)
Characteristic
description.
1403 A very short France. Described in
epidemic. France. In 1404
(Gluge, it invaded
Ripperger, Flanders and
Pasquier.) Germany
(Hirsch).
1411 Described only Described only Described by
in Paris. in Paris. Pasquier as in
Extent Paris.
unknown.
1414 Characteristic In Italy and
description. France in
February and
March. In the
Danube district
between
January and
April.
1427 Very Described in
 characteristic France.
description.
1438 Cited only by Described in
Zeviani. Italy.
1482 Very limited
description
by Mezeray.
1510 Widespread Malta (?) Generally, from Malta, Sicily,
over all of (Webster and South to Spain and
Europe. Hancock North. Portugal, Italy,
report that it France,
began in Hungary,
Africa). Germany,
Holland,
England,
Norway.
1557 All of Europe. Conflicting General direction Asia, 4 months from
information from South to Constantinople, Italy to
(Asia?). North in Sicily, Italy, Netherlands.
Europe. Spain, Sicily in June.
Dalmatia, Nimes in July.
Switzerland, Italy in August.
France, Madrid in
Netherlands, August.
England. Dalmatia in
September.
Netherlands in
October.
1562 Uncertain Only small
1563 information. epidemics at
most.
1580 True pandemic Orient (Hirsch) From Asia to Orient, North France in May.
covering the Africa and Constantinople Africa, Germany and
Orient, Africa Malta and in Europe Constantinople, Hungary in
and Europe. (Pechlin). from South to Malta, Venice, August.
North. Sicily, Italy, England and
Spain, Hungary Rhine Valley in
and Germany September.
to the Baltic, Saxony in
Bohemia, October.
France,
Belgium,
England,
Denmark,
Sweden.
1587 Apparently Described in Italy
quite and Germany.
localized.
1591 High mortality.
Indefinite
information.
1593 Spread over a Said to have Uncertain.
wide area in commenced
Europe. in Belgium,
“following a
violent
 earthquake,”
and gradually
extended over
all the cities of
Europe.
1626 Local. Described in
Italy.
1627 In America. Spread from
North America
to West Indies
and Chili.
1647 In America
(Webster).
1658 Local. England (?). Described in
England and in
Treptow near
Stettin.
1675 Over Western Germany (?). Germany, Germany in
Europe. Hungary, September,
England, England and
France. France in
October and
November.
1688 Apparently England(?). Described only in
localized in England and
Great Britain Ireland.
and Ireland.
1693 England and Dublin(?). Dublin, Oxford, One month from
the adjacent London, Dublin to
continent. Holland, London.
Flanders.
1709 A period of In 1712, onset in 1712, spread Italy, France, Six months from
1712 extensive Germany. from Germany Belgium, Germany to
endemics. to Holland and Germany, Italy.
Italy. Denmark.
1729 First epidemic Usually Russia through Moscow, Sweden, Moscow in April,
said to have designated as Sweden, Poland, Silesia, 1729. Sweden
originated in Russia Poland, Austria, in September,
Russia and (Moscow). F. Germany, etc. Hungary, England in
first Hoffman to Italy and England, November.
described as claimed to perhaps North Switzerland, Paris in
entering have seen the America. France, Italy, December.
Europe from epidemic in Iceland. Rome in
the Northeast Halle in February,
rather than February, 1730.
the 1729.
Southeast.
First spread.
Pandemic
period.
1732 Second spread. Over Europe and Germany in
Pandemic America. November.
period. According to France in
Pelargus it January, 1733.
again followed Spain and Italy
the route from in February.
 Russia through
the North of
Europe and
then South.
1737 Not generally England, North
recognized. America,
Barbados,
France.
1742 Slow spread Began either on Occurred in Germany, Germany in
1743 from the shores of Germany in Switzerland, January, 1742.
Germany. the Baltic Sea Jan. and Feb., Italy, France, England in
Recurrences or in single 1742, and then Holland, April, 1743.
in Germany cities in disappeared to Belgium,
up until 1745. Germany. reappear in England.
Switzerland in
the spring.
1757 A period of Began either France, Scotland, Barbados, Villalba states
1758 related first in North America, Germany, that the
1761 epidemics America and Finkler states Austria, epidemic in
1762 with spread thence that in 1762 Hungary, 1767 had
1767 complicated to Europe or influenza first Denmark, traveled over
geographic else began started in England, the whole of
pictures and spontaneously Germany and Ireland, Alsace. Europe in a
without clear in both spread thence period of two
cut direction hemispheres. in a very months.
of spread. irregular way
over Western
Europe. Gluge
and Hirsch
state that in
1767 the
disease
appeared
simultaneously
in Europe and
North
America.
1775 Slow spread First First spread to Germany, Italy, Invaded Vienna
1776 through appearances Vienna, and Austria, in June. Made
Western in Autumn of after a England, appearance in
Europe. 1775 in village quiescence Ireland, France. Italy in
of Clausthal in broke out in September. In
the Harz France and England and
mountains. England and France in
possibly October,
spread to November and
America and December.
China.
1780 Western January, 1780 in Spread to Alsace, Three months
1781 Europe and France. Germany and from France to
possibly Italy, and in Brazil.
Brazil and March
China. reported in Rio
de Janiero.
Appeared in
Sept. 1780 on
 Southern coast
of China.
1781 One of the most China and Through Siberia China, India, Moscow,
1782 widespread perhaps India and Russia to America, January, 1782.
pandemics. in Autumn of Petrograd, Russia, Riga, Riga,
Abundant 1781 (Hirsch). Finland, Riga, Germany, February.
literature. English Germany, etc. England, Germany,
writers Scotland, March.
connect onset Netherlands, England, April.
with Ireland, France, Scotland, May.
occurrence of Italy, Spain. Ireland,
influenza in France and
the British Italy, June.
Army in India, Spain, August.
Nov., 1781.
Wittwer and
others begin
its history in
Petrograd in
January, 1782.
1788 Throughout all Russia, in West and South. Russia, Germany, Seven months
1789 of Europe. March, 1788. Spread in Hungary, required to
One year “Apparently America in Denmark, cover this
later in independent 1789 England, territory.
America. origin in throughout Scotland,
America in United States France, Italy,
Sept., 1789.” from New York Switzerland.
North and
South and
finally
touching the
West Indies,
South America
and Nova
Scotia.
Recurrences in
single cities of
U. S. in 1790.
1799 Local epidemic Origin in Russia. Spread West and Russia, Galicia,
1800 confined to South. Poland,
Northeastern Germany,
Europe. Denmark.
1802 Local endemic First reported in No clear cut France, Germany,
1803 outbreaks France. direction. Italy, England,
covering Recurrences Switzerland,
considerable until 1805–08. Central Europe.
territory General
which follow dissemination
the last throughout
period by a North America
quiescence of in 1807.
five months.
There
appears to
have been an
unassociated
epidemic
 early in 1800
in China and
one in Brazil.
1811 Several 1807, onset in Usually from North and South 1815, one month
1815 epidemics in Massachusetts New England America. from Boston to
1816 North in February. West and New York, and
1824 America and 1815, onset in South. five months to
1826 to some Boston in South Carolina
extent in September. and Brazil.
South 1824, onset in 1824, three
America. Boston in months from
October. Boston to
Georgia.
1827 Widespread
epidemics
throughout
Eastern
Russia and
Siberia.
1830 Extensive China in To Manila in Entire earth. Ten months from
1833 influenza January, September, China to
period made 1830. 1830. Later to Russia. Four
up of two or South Sea months from
three Islands and Russia to
pandemic India. Germany. Two
periods. Appearance in additional
Russia in months
October, 1830, through
with France,
subsequent England,
spread West Scotland,
and South and Sweden,
on to North Belgium,
America (Feb., Switzerland.
1832). Six months
from Germany
to Italy.
1833 Second Probably Asia. After an interval Europe. (America Petrograd in
pandemic in of one year appears to have January.
above period. Europe was escaped this Berlin and
again visited second Constantinople
with an epidemic.) in March.
extensive Denmark and
plague which Sweden,
attacked the France and
same countries Great Britain
in about the in April, Italy
same order. in May.
1836 Third spread in Origin rather West and South Europe, Faroe Almost
1837 above period. obscure, as previously. Islands, simultaneous
possibly in Mexico,(?) invasion at
Russia. India, Java. Petrograd,
Sweden,
Denmark,
Germany and
England;
Egypt, Syria,
 France,
Ireland,
Holland, and
Switzerland
one month
later. Italy,
Spain and
Portugal yet
another month
later.
1838 Every year in 1838, February;
1847 this period Island of
with the Bourbon and
exception of Iceland.
1840 showed, 1838,
according to November;
Hirsch, some Australia and
local New Zealand.
epidemic. 1839,
Abyssinia.
1841, Germany,
Hungary,
Ireland.
1842, Belgium,
England,
France, Egypt,
Chili.
1843, Germany,
England,
Iceland,
France, Siberia,
the United
States.
1844, Germany,
England,
Switzerland,
Cayenne.
1845, Germany
and
Switzerland.
1846–1847,
France, Russia,
Constantinople,
Brazil,
England,
Denmark,
Belgium,
Switzerland.
1847 Epidemic Origin Spread not All of the
1848 period uncertain. definite, North countries of
throughout America in Western
Europe 1848. Europe, West
without clear Indies, New
cut direction Zealand,
of spread. Newfoundland,
Sandwich
Islands, Egypt,
 Algiers, West
Coast of Africa.
1850 Epidemics 1857, began in 1850–51, 1855, only one
1889 covering August in particularly month
larger or Panama and throughout the between
smaller spread to West whole Western Petrograd and
territory Indies and up coast of South Italy.
every year, and down the America with
but none to Pacific Coast. later spread to
compare in Prevailed in California &
intensity with Europe in Europe.
those of 1831, December. 1852, Australia,
1833, 1836 Tasmania,
and 1847. South America.
1853, Faroe
Islands.
1854, Bavaria.
1855, Europe,
spreading
rapidly West
and South from
Petrograd.
Later in same
year, Brazil.
1857–58,
widespread
epidemic in
both
hemispheres.
1860–70, very
irregular
appearances in
Australia,
Tasmania,
Philadelphia,
the Bermudas,
Holland,
California,
France,
Switzerland,
Africa,
Germany,
Belgium,
Russia,
Denmark,
Sweden and
Turkey.
1874–75,
Extensive
spread in
America,
Germany and
France, with
recurrence one
year later in
eleven areas of
the United
 States.
1879, America.
1885–88, Re-
appeared each
year in
Petrograd.
1889, (Spring)
Greenland and
Hudson Bay
territory. (May)
Bokhara in
Turkestan from
where the great
pandemic of
1889–90 is
usually said to
have taken its
origin.
Table I shows that prior to 1510 the information was so limited as to be not entirely
conclusive. We must rely upon the fragmentary descriptions of writers located usually in
or near the intellectual centers who described the disease as they saw it in their city or
country. We have no way of ascertaining what other countries were invaded, and we
possess no method by which we may enumerate the “silent areas,” countries which in
the absence of a chronicler have not been able to transmit their story.
There have been fourteen very widespread epidemics since 1510, all of which might
appropriately be designated as pandemics. They are those of 1510, 1557, 1580, 1593,
1729, 1732, 1762, 1782, 1788, 1830, 1833, 1836, 1847, 1889 and 1918. Some of these have
spread farther than others according to the records, but in nearly all we have reports of
influenza being present in practically every country provided with a historian. We may
find from the table another group in which there have been more or less extensive
epidemics, apparently related, but without any general direction of spread. Such are the
epidemics of 1709–12, 1757–67, 1802–03, 1838–47 and the period 1850–59. Finally,
there are at least ten periods during which relatively small areas have been affected with
epidemic influenza. Such for instance is the year 1688 when the disease was apparently
localized in Great Britain and Ireland; in the year 1693 when England and the adjacent
continent were involved, with little spread elsewhere; and again in 1742, when there was
a slow spread through Germany into adjacent countries with recurrences in the former
up until 1745.
In England the following epidemics have been recorded, some of them in great detail:
1510 and 1557, described by Thomas Short; 1658 by Willis; 1675, by Sydenham; 1729–
1743 by Huxham; 1732–33 by Arbuthnot; 1758 by Whytt; 1762 by Baker and Rutty; 1767
by Heberden; 1775 by Fothergill, who collected observations from many physicians; in
1782 by Gray, Haygath and Carmichael Smith; 1803 by Pearson and Falconer, and a
great number of others; 1833 by Hingeston and others; 1837 by Streeten, Graves, and
Bryson, etc.; 1847 by Peacock, Laycock and many others; also those of 1855 and 1889–
93.
According to Stallybrass, epidemic crests have been reached in England in 1789–90,
1802–03, 1830–32, 1840–41, 1848–51, 1854, 1869–70, 1879, 1890–91, 1898 and 1918
to 1920. The periodicity in multiples of ten years in this latter group is remarkable.
The disease appears to have visited North America in the years 1627, 1647, 1729, 1732,
1737, 1762, 1782, 1789, 1811, 1832, 1850, 1857, 1860, 1874, 1879, 1889, 1900, 1915–1916
and 1918–20. Abbott speaks particularly of the years 1647, 1655 and 1697–98, 1732,
1762 and 1782 and 1889 as being years of especial epidemic prevalence in this country.
 Clinical and Epidemiologic Identification.
Up to the present time we have discovered no one characteristic by which we may say
that a case or an epidemic is positively influenza. We have had to rely on the general
symptomatology, which indeed is sufficiently characteristic, although so nearly like the
symptoms of certain other diseases as to make us hesitate to make an absolute
diagnosis, and on the epidemic characteristics. The necessity of an absolute criterion in
the clinical diagnosis is particularly felt in the presence of an isolated interepidemic
case, or a small endemic outbreak. It is at this point that the opinions of epidemiologists
diverge, a divergence which results in two schools of thought in the explanation of the
endemic source of epidemic influenza. Are the interepidemic cases and the small
localized epidemics due to the virus which causes the great pandemics; are they
influenza vera, or are they entirely different diseases with similar symptomatology,
caused by some other microorganism and should they be designated by some other
name? Thus Leichtenstern remarks: “When we go over the records of the years 1173 to
1875, and particularly those of the last century, when the information has been more
extensive and more accurate, we find that scarcely a year has passed without news of the
epidemic occurrence of influenza at some point or other of the earth. Some of these local
and territorial epidemics are merely endemic recurrences of the great pandemics which
have left the germ deposited in the various localities. Others of these small epidemics
probably have nothing to do with influenza vera, but are local outbreaks of catarrhal
fever.”
Contrary to the usual belief, influenza is a disease of quite definite and distinct
characteristics, both clinical and epidemiological. The symptoms are clear cut, with
sudden onset, severe prostration out of all proportion to the clinical symptoms and to
the fever, headache and pain in the back, general body pains, and fever of greater or less
degree. There is usually a lack of leucocytosis or a true leucopenia. In uncomplicated
influenza there are as a rule no localizing symptoms. There may be a slight soreness of
the throat, or a slight cough, but these are at best mild. The fever lasts from three to five
days and disappears, while at the same time all of the symptoms clear up with the
exception of the profound prostration, which as a rule continues for some time,
rendering convalescence surprisingly slow. The pain in the back may remain for a week
or so. This is the description of uncomplicated influenza.
The manner of spread of epidemic influenza is constant in a primary epidemic and the
epidemic as a whole has certain features which render it characteristic. The sporadic
case has as a rule the same quite clear cut clinical symptomatology, but it fails to
manifest the one feature most characteristic of epidemic influenza—a high degree of
contagiousness. Further, although the symptoms in themselves are characteristic, there
is no one pathognomonic sign by which one may say, “this is a case of influenza,” and,
finally other disease conditions such as tonsillitis, frequently resemble it so much as to
cause error in diagnosis.
This becomes, then, one of the problems in the study of influenza epidemiology. It is a
matter of first importance to determine once and for all whether true influenza is with us
always, or whether it appears only at the time of the great pandemics. Upon the answer
to this question more than upon any other one thing rests our choice of methods of
eradication. Any procedures of preventive medicine that may be undertaken on the
assumption that the source of pandemic influenza is to be found in one or a few endemic
foci, such as the one supposed to exist in Turkestan, would fail utterly should the true
condition be that of a universal distribution of a relatively avirulent virus which from
time to time from some unknown cause assumes a highly increased virulence.
Before becoming involved in this very complicated question, let us familiarize
ourselves completely with the characteristics of the pandemic and epidemic variety of
the disease.
 General Characteristics of Early Epidemic
Outbreaks.
We have described the symptomatology of uncomplicated influenza. It is rare that this
clinical picture is seen alone during the height of an epidemic. Complications, chiefly of
the respiratory tract, as a rule occur in such a large proportion of individuals that they
very nearly dominate the picture. Although caused by various microorganisms, all of
which appear to be secondary factors the results are so characteristic that in the past,
descriptions of influenza epidemics have usually been descriptions of the complications
of epidemic influenza. Most influenza epidemics are complicated. But we do know from
the experience of recent years as well as from history that relatively uncomplicated
epidemics of influenza have occurred, and that when they do so occur a predominant
characteristic has been the extreme mildness.
It is a fundamental characteristic of pandemic influenza that early cases in widespread
epidemics, as well as in “pre-epidemic increases” are very mild, with a minimum of
respiratory complications and with exceedingly low mortality. It is because we are better
acquainted with the more severe variety that, when these mild precursors appear we are
always in doubt for a time as to their true identity.
In spite of our 20th century erudition, the influenza when it first appeared in mild
form in the American Expeditionary Forces in 1918, for a lack of better knowledge as to
its cause was called “three-day fever.” In Italy in the same year the designation of the
disease progressed from pappataci fever through “Spanish grip” and “summer
influenza,” until finally it was designated influenza, pure and simple. Sampietro in Italy
particularly discussed the possibility of the disease being pappataci fever.
Belogu and Saccone, who wrote in May of 1918, decided that the epidemic was not
influenza in spite of the manifest clinical similarity, chiefly because of the absence of
signs of secondary invasion, such as nervous symptoms, gastro-intestinal symptoms,
and pneumonia, and especially because of the rapid recovery after defervescence. They
also considered the possibility of pappataci fever and dengue, and ruled out both. They
discussed calling the condition “influenza nostras,” but reached no definite conclusion.
Trench fever was also considered by some. United States Public Health Reports for 1918
record that dengue was reported prevalent at Chefoo, China, during the two weeks
ended June 15th, 1918. One week later there was a paragraph stating, “Prevalence of a
disease resembling dengue and affecting about fifty per cent. of the population was
reported at Shanghai, China, June 15, 1918.” It is not impossible that this was influenza.
Zinsser reminds us that Hayfelder, when he saw the influenza as it spread in
Petrograd in November of 1889, remarked its close clinical similarity to the description
of an epidemic of dengue which had prevailed in Constantinople during the preceding
September. Hayfelder, in studying the 1889 epidemic at its onset in Russia and the East,
wrote of “Sibirisches Fieber” which was first looked upon as malaria owing to the
apparently complete absence of the complicating lesions habitually associated in our
minds with influenza.
The same difficulty in early identification was experienced in this country in 1918. At
the end of March of that year the author who was stationed at Camp Sevier, South
Carolina, was one of a Board of Officers appointed to investigate a disease which had
broken out among troops stationed at that camp. At that time the line troops consisted
of three infantry regiments and three machine gun battalions. On the day following a
parade in the city of Greenville a considerable number of men in three out of the six
organizations suddenly took ill. There were a few isolated cases in other organizations,
but in the one infantry regiment and two machine gun battalions the regimental
infirmaries were filled, and some cases were sent to the base hospital. Nearly all were
very mildly ill and exhibited the symptoms of pure uncomplicated influenza as described
above. The onset was sudden, there were the usual pains and aches, the bowels were
regular, there was a feeling of discomfort in the pit of the stomach in many instances,
and there were no sore throats and very little cough. Recovery was as a rule very rapid,
although about a dozen of the entire number developed pneumonia and some of these
died. Physical examination of those only mildly ill and who remained in the regimental
infirmary showed as a rule nothing, but in some instances scattered fine moist rales near
the hilus of the lungs. In some of the organizations the disease was definitely spread
down rows of company tents. Careful bacteriologic examination was made at the time
and the predominating organisms were found to be a gram-negative coccus resembling
micrococcus catarrhalis, and a non-hemolytic streptococcus. This was in uncomplicated
cases.
The Board decided that the disease should be called influenza, but our only basis for
such decision were the clinical symptoms and the contagious character. At that time
none of us dreamed of any possible connection with a severe epidemic to occur later,
and laboratory search for influenza bacilli which was carefully made in view of the
clinical diagnosis showed none of these organisms to be present.
At about the same time a similar epidemic was being experienced at Fort Oglethorpe,
Ga. V. C. Vaughan, in describing this epidemic, remarks: “A disease strongly resembling
influenza became prevalent in the Oglethorpe Camp about March 18, 1918. It soon
assumed pandemic proportions. Within two weeks every organization in Camp Forrest
and the Reserve Officers Training Camp was affected.
“The symptoms were as follows: Headache, pain in the bones and muscles, especially
the muscles of the back, marked prostration, fever, sometimes as high as 104 degrees.
Sometimes there was conjunctivitis, coryza, a rash and possibly nausea, recovery taking
place in a few days.
“In all organizations the epidemic was first located in companies before it became
general.
“The incubation period was short, not over one or two days.
“Some organizations suffered more than others for no apparent reason.
“It is probable that the epidemic disease was recently brought to these camps. If it is
genuine influenza, and the epidemiological features no less than the leading symptoms
seem to point to that disease, there is here offered the most reasonable explanation of
the outbreak which is now possible. No other disease spreads so fast or is so prostrating,
considering its symptoms.”
We will quote at some length from the report of Zinsser of the Chaumont epidemic in
France in 1918, because of the excellence of the description, and particularly because
Zinsser has followed three successive epidemics with successive increases in the
complications and corresponding transformations in the clinical picture. It is worthy of
special note that he has remarked that the influenza, as first seen at Chaumont, showed
nothing in the symptoms that would suggest a predominant respiratory tract infection.
 “It will be useful to discuss briefly the early cases as we saw them during the
Chaumont epidemic, not because the observations made there add much that is new
from a clinical point of view, but because they will remove any possible ambiguity
concerning our conception of influenza in its pure uncomplicated form.
“As far as we can judge the little outbreak at headquarters was typical of the first
advent of epidemic influenza in many places. The population of the town, at the time,
consisted of a large office personnel attached to the military administration, scattered as
to billets and places of work; of military units living in barracks and eating at common
messes; and of the townspeople. The epidemic descended upon individual military units
with the suddenness of a storm, striking a considerable percentage of the men, perhaps
most of the susceptible material, within less than a week, and ending almost as abruptly,
with only a few isolated cases trailing behind. Among the more scattered office workers
and among the townspeople it was disseminated more gradually and trailed along for a
longer period.
“These early cases were clinically so uniform that a diagnosis could be made from the
history alone. The onset was almost uniformly abrupt. Typical cases would become ill
suddenly during the night or at a given hour in the day. A patient who had been perfectly
well on going to bed, would suddenly awake with a severe headache, chilliness, malaise
and fever. Others would arise feeling perfectly well in the morning, and at some time
during the day would become aware of headache and pains in the somatic muscles.
“The typical course of these cases may be exemplified by that of J. T. W., a draftsman
attached to the 29th Engineers. He was perfectly well until May 20th, working regularly,
his bowels and appetite normal, considering himself healthy. On May 21st, at 4:30 A.M.
he awoke with a severe headache. He arose, forced himself to eat breakfast and tried to
go to work. He began to feel feverish and chilly. At the same time his headache became
worse, with pains in the back, and burning in the eye balls. At 2 P.M. he reported sick,
and was taken to the hospital with a temperature of 102.8 degrees. At midnight his
temperature dropped to 101.6 degrees, and came down to normal by noon of the 22d. As
he recovered he developed a slight sore throat, great soreness of the legs and a very
slight cough. He recovered completely within a few days.
“These cases with a few exceptions developed no rashes. One or two of them had
blotchy red eruptions which we felt incompetent to characterize dermatologically. The
leucocyte counts ranged from 5,000 to 9,000. A very few went above this. Sometimes
there was a relative increase of lymphocytes, but this was by no means regular. The few
spinal fluids that were examined were normal. As to enlargement of the spleen, we can
say nothing definitely.
“Soon after this we observed the disease in a Division, the 42d, then holding a part of
the line in front of Baccarat. Here it had already developed a somewhat different nature,
due, we believe, to the fact that the men of this Division were not, as were those at
Chaumont, living in a rest area, but were actively engaged in military operations,
working, sleeping, and eating under conditions that involved greater fatigue, less
protection against weather, and greater crowding in sleeping quarters. The Baccarat
cases were much more frequently catarrhal; sore throats, coughs and more serious
respiratory complications were more common. However, they were usually coupled
unmistakably with an underlying typical influenzal attack, sudden onset, pains and short
lived fever. Moreover, there were a great many of the entirely uncomplicated cases
interspersed with the others.
 “Still later, in September, October and November, respiratory complications were so
frequent and severe, came on so early in the disease, and the pneumonia mortality
became so high, that the fundamental identity of these later cases with the early three-
day fever might easily have been lost sight of by observers who had not followed the
gradual transformation.
“In consideration of these facts, it is apparent that etiological or other investigations
can throw no light upon the problems of influenza unless they are carried out with
clearer understanding of the differentiation between the complications and the basic
disease.
“The serious respiratory infections of the bronchi and lungs we can set down with
reasonable certainty as complications due, certainly in the overwhelming majority of
cases, to secondary bacterial invaders. It is a matter of considerable difficulty, however,
to know exactly where the basic disease stops and the complications begin; and whether
we must regard the mild sore throat and conjunctival injection which so often
accompany the simple cases as a part of this basic clinical picture, or as the simplest
variety of complication. This is much more than an academic question, since, as we shall
see, the bacteriological analyses of such lesions have played an important role in
etiological investigations.”
 Symptoms in Former Epidemics.
The difficulty in making a decision in the presence of an epidemic is very similar to
that of deciding whether the epidemics of former times were in each case influenza.
Some few have been recorded in which the description has corresponded fairly well to
that of primary uncomplicated influenza. Thus, concerning the epidemic of 1557 in
Spain, Thomas Short wrote as follows: “At Mantua Carpentaria, three miles from
Madrid, the epidemic began in August.... There it began with a roughness of the jaws,
small cough, then a strong fever with a pain of the head, back, and legs. Some felt as
though they were corded over the breast and had a weight at the stomach, all of which
continued to the third day at furthest. Then the fever went off, with a sweat or bleeding
at the nose. In some few, it turned to a pleurisy or fatal peripneumony.”
Most of the descriptions, however, have been of a general character and include
descriptions of the complicated periods of the epidemic. One of the more complete of the
early descriptions was that by Lobineau in 1414, who wrote: “C’était une espèce de
rhume, qui causa un tel enrouement que les chastelets furent obligez d’interrompre leurs
séances; on dormoit peu et l’on souffroit de grandes douleurs à la teste, aux reins et par
tout le reste du corps; mais le mal ne fut mortel que pour les vieilles gens de toute
condition.”
With this exception we possess no very good or complete description of influenza
prior to the epidemic of 1510. After that time they have as a rule been detailed enough to
enable identification. Hirsch bases his conclusions concerning the year 1173 chiefly on
the following quotation: “Sub hisdem diebus universus orbus infectus ex aeris nebulosa
corruptione, stomacho catarrhum causante generalem tussim, ad singulorum perniciem,
ad mortem etiam plurimorum immissam vehementer expavite.” Nearly all that we have
to go on in this description is the widespread incidence of the disease and the presence
of respiratory symptoms, particularly cough. In 1323 the description emphasizes only
the high morbidity. Thus, Pietro Buoninsegni writes: “In questo anno e d’Agosto fu un
vento pestilenzia le per lo quale amalò di freddo e di febbre per alcuni dì quasi tutte le
persone in Firenze e questo madesimo fu quais per tutta Italia.” The same author
describes the epidemic of 1327, emphasizing again the high morbidity and in addition
the low death rate: “In detto anno e mese fu quasi per tutto Italia corruzione di febbre
per freddo; ma pochi ne morirono.” Again in 1387, he emphasizes the same two features.
Pasquier, in writing of the epidemic of 1403 in France, says: “En Registres de
Parlement on trouve que le vingt-sixième jour d’avril 1403 y eut une maladie de teste et
de toux, qui courut universellement si grande, que ce jour-là le Greffier ne pût rien
enrégistrer et fut-on contraint d’abandonner le plaidoyé.” Here the high morbidity and
the symptoms, particularly cough and pain, are emphasized. In 1414, Baliolanus
describes again the high morbidity and symptoms, particularly cough and hoarseness:
“Eoque frigore humanis corporibus concepto ... tussis maxima atque raucitas orta unde
nullus pene ordo, aetas et sexus liber evasit.” In 1411, Pasquier writes the following: “En
1411 y eut une autre sorte de maladie dont une infinité de personnes furent touchez, par
laquelle l’on perdoit le boire, le manger et le dormir ... toujours trembloit et avec le estoit
si las et rompu que l’on ne l’osoit toucher en quelques parts. Sans qu’aucune personne
en mourut.”
 Subsequent to 1510 descriptions have been as a rule more definite. There are,
however, exceptions to this statement and these fall in the epidemics concerning which
there is some dispute.
 Manner of Spread.
More characteristic and more important from an epidemiologic standpoint than the
symptomatology in general, as we have discussed it, is the mode of development of the
epidemic as a whole.
Human intercourse.—Before the days of bacteriology the contagiousness of the
disease was little discussed. Its infectiveness was in fact not universally established until
the epidemic of 1889–1890. One of the first writers who attempted to see in the
influenza a contagious disease was Ch. Calenus who wrote in 1579: “Contagiosum dico
morbum, quia etsi quidem ab occulta quadam coeli influentia, principaliter eum profisci
haud dubium est ... eo in loco quo jam grassabatur inter homines citius eos invadabat,
qui cum affectis frequenter conversabantur, quam eos, qui a consuetudine affectorum
studiose abstinebant.” This keen observer saw that those who carelessly exposed
themselves to close contact with cases of influenza were more likely to develop the
disease than those who protected themselves in every way possible. The “contagious”
school first developed in England, where Haygarth, Hamilton, Gray, Hull, Duggard,
Bardsley, and others, in 1775–1803 described the disease as being not in the air, but in a
specific contagion. Others who considered influenza a contagious disease were Simonin,
Lombard, Petit de Corbeil (1837), Blanc (1860), and Bertholle (1876).
Watson (1847) quotes Cullen as saying that this species of catarrh proceeds from
contagion. He, himself, is not convinced of this fact. He says the visitation is too sudden
and too widely spread to be capable of explanation in that way. “There are facts in the
history of influenza which furnish a strong presumption that the exciting cause of the
disorder is material, not a mere quality of the atmosphere; and that it is at least
portable. The instances are very numerous, too numerous to be attributed to mere
chance, in which the complaint has first broken out in those particular houses of a town
at which travelers have recently arrived from infected places.... What I wish to point out
now is the fact that the influenza pervades large tracts of country in a manner much too
sudden and simultaneous to be consistent with the notion that its prevalence depends
exclusively upon any contagious properties that it may possess.”
Parkes, writing in Reynolds’ System of Medicine in 1876, views the subject more as we
see it today: “The rapidity of the spread would seem at once to negative any connection
between human intercourse and the propagation of the disease; yet there is some
affirmative evidence. It does not appear to follow the great lines of commerce; but when
it has entered towns and villages in which the investigation can be carried on, it is
curious how frequently the first cases have been introduced, and how often the
townspeople nearest the invalids have been first affected. In this country especially,
Haygarth in 1775 and 1782, and Falconer in 1802, collected so many instances of this
that they became convinced that its propagation was due entirely to human intercourse.
So also, when it passes through a house, it occasionally attacks one person after another.
But if it is introduced in this way it afterwards develops with marvelous rapidity, for we
cannot discredit the accounts of many thousands of persons being attacked within a day
or two, which is quite different from the comparatively slow spread of the contagious
diseases. This sudden invasion of a community makes it, to many persons, appear highly
improbable that any effluvia passing off from the sick should thus so rapidly
contaminate the atmosphere of a whole town.