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The Threat of Pandemic Influenza: Are We Ready? - Workshop Summary
manner, in some families all were sick together, in some towns almost all were sick so that it was a time of disease” (Pettit, 1976). In London in 1847 and 1848, more people died from influenza than from the terrible cholera epidemic of 1832. In 1889 and 1890, a great and violent worldwide pandemic struck again (Beveridge, 1977).
But 1918 seems to have been particularly violent. It began mildly, with a spring wave. In fact, it was so mild that some physicians wonder if this disease actually was influenza. Typically, several Italian doctors argued in separate journal articles that this “febrile disease now widely prevalent in Italy [is] not influenza” (Policlinico, 1918). British doctors echoed that conclusion; a Lancet article in July 1918 argued that the spring epidemic was not influenza because the symptoms, though similar to influenza, were “of very short duration and so far absent of relapses or complications” (Little et al., 1918).
Within a few weeks of that Lancet article appearing, a second pandemic wave swept around the world. It also initially caused investigators to doubt that the disease was influenza—but this time because it was so virulent. It was followed by a third wave in 1919, and significant disease also struck in 1920. (Victims of the first wave enjoyed significant resistance to the second and third waves, offering compelling evidence that all were caused by the same virus. It is worth noting that the 1889–1890 pandemic also came in waves, but the third wave seemed to be the most lethal.)
The 1918 virus, especially in its second wave, was not only virulent and lethal, but extraordinarily violent. It created a range of symptoms rarely seen with the disease. After H5N1 first appeared in 1997, pathologists reported some findings “not previously described with influenza” (To et al., 2001). In fact, investigators in 1918 described every pathological change seen with H5N1 and more (Jordon, 1927:266–268).
Symptoms in 1918 were so unusual that initially influenza was misdiagnosed as dengue, cholera, or typhoid. One observer wrote, “One of the most striking of the complications was hemorrhage from mucous membranes, especially from the nose, stomach, and intestine. Bleeding from the ears and petechial hemorrhages in the skin also occurred” (Ireland, 1928:57). A German investigator recorded “hemorrhages occurring in different parts of the interior of the eye” with great frequency (Thomson and Thomson, 1934b). An American pathologist noted: “Fifty cases of subconjunctival hemorrhage were counted. Twelve had a true hemotypsis, bright red blood with no admixture of mucus…. Three cases had intestinal hemorrhage” (Ireland, 1928:13). The New York City Health Department’s chief pathologist said, “Cases with intense pain look and act like cases of dengue … hemorrhage from nose or bronchi … paresis or paralysis of either cerebral or spinal origin … impairment of motion may be severe or mild, permanent or temporary … physical and mental depression. Intense