Reprinted from the New York Medical Journal for 
January 25, 1919. 
(Published by Authority of the Surgeon General, 
United States Army.') 
INFLUENZA EPIDEMIC 
At United States Army General Hospital No. 17, 
Markleton, Pa. 
By Major Philip A. Loomis, 
Medical Corps, U. S. Army, 
AND 
Captain Joseph Walsh, 
Medical Corps, U. S. Army. 
Our epidemic was unique in that we know the 
original case from which all others developed. For 
ten days previous to the admission of this case, the 
most rigid quarantine had been observed. The vil- 
lage of Markleton has but fifty-two inhabitants and 
we know that there were no cases of influenza 
among them. On October 13, 1918, a passing troop 
train consigned to our care a patient with an ex- 
tremely malignant case of influenza. When put to 
bed he had a temperature of 104°, pulse 100, respira- 
tion 34, and the typical symptoms of a fully de- 
veloped influenza with intense prostration, injected 
eyes, extremely red soft palate and fauces, and a 
short hacking cough. Though not present on ad- 
mission, typical signs of bronchopneumonia began 
to show themselves at seven o'clock the next even- 
ing, October 14th, were fully developed the follow- 
ing day, October 15th, and he died on October 16th, 
at 4:45 p. m. The autopsy showed bronchopneu- 
monia of both lower lobes, the left being completely 
involved and the right to the extent of about fifty 
per cent. 
This first patient was carefully isolated in a pri- 
Copyright, 1919, by A. R. Elliott Publishing Company. Loomis and Walsh: Influenza Epidemic. 
vate room on the third floor of a detached building 
which had been cleared out several days before in 
anticipation of a possible epidemic. Previous to 
death and for several days after, no one was al- 
lowed on the floor except the physicians, nurse, and 
on the last day an attending corps man. The chief 
Chart I.-Characteristic temperature chart in bronchopneumonia 
case; slight remission on the third day and final almost abrupt 
drop following the eleventh day. 
of the laboratory who saw him once on October 
15th to examine his blood, manifested the disease 
the next evening. The medical chief visited him 
on October 14th, 15th, and 16th and was taken ill 
on the 17th. The surgical chief saw the case only 
2 Loomis and IValsh: Influenza Epidemic. 
at autopsy on October 16th, but came in contact 
with the chief of the laboratory all day October 
16th and the disease had fully developed on the 
17th. The nurse who attended the first case from 
October 13th to 16th showed definite symptoms on 
the 17th. All four of these cases showed the typical 
Chart II.-Shows gradual rise after first remission and abrupt 
fall simulating a crisis. 
signs of influenza and later bronchopneumonia, the 
chief of the laboratory dying October 22nd, the 
other three passing through severe sieges and re- 
covering. On October 18th the disease developed in 
the wife of the chief of the laboratory; on the 20th. 
a nurse in attendance on the influenza patients; on 
3 Loomis and Walsh: Influenza Epidemic. 
October 22nd, two nurses in attendance; and on 
October 30th, the head nurse who had been caring 
for the sick nurses for ten days. In the meantime 
the disease also developed in eighteen enlisted men 
and three tuberculous patients. Of these thirty-one 
patients, pneumonia developed in eight. All but 
one of these eight had been in direct contact with 
the original patient or with the chief of the labora- 
tory, both of whom died. 
All physicians, nurses, and enlisted men, who 
came in contact with patients wore masks and 
gowns, and were carefully instructed in regard to 
precautions, though evidently without avail. Doc- 
tors, nurses, and attendants helped to feed the 
flames and fill the wards until an immune staff was 
found. It is interesting to observe that out of two 
hundred tuberculous patients the disease developed 
in only three, while twenty-eight cases occurred 
among our personnel of one hundred. 
SYMPTOMS AND COURSE OF DISEASE. 
Incttbation.-Of the ten cases in whom the date 
of primary exposure was known with certainty the 
disease developed in nine in from one to three days; 
the tenth came down with the infection only after 
ten days' exposure, but it might be noted that this 
individual was over forty. 
Onset.-As these cases developed among the 
hospital personnel and patients, we feel certain of 
having seen even the mildest cases on the appear- 
ance of the first symptom. In the majority of in- 
stances the onset was abrupt. The predominating 
features were head and general bodily aches, fever 
of ioi° or higher, more or less cough, and in more 
than one half of the cases injection of the fauces 
and conjunctiva. Coryza was conspicuously ab- 
sent. Chilliness was rare, and when amounting to 
a chill was found to indicate some other condition 
than influenza. Prostration was not often com- 
plained of at onset. The pulse was slow, and 
4 Loomis and Walsh: Influenza Epidemic. 
respiration not much increased. Epistaxis oc- 
curred in ten per cent, of the cases. The cases 
may be divided into two principal groups for 
purposes of description, the simple form, and 
one of more severe type, spoken of hereafter for 
convenience as the pulmonary form. In the simple 
form temperature persisted from two to seven days, 
Chart III.-The temperature in two definite stages, finally falling 
on the seventh day. 
averaging five, and subsiding gradually. The symp- 
toms usually abated on the second or third day and 
the pulmonary evidences, like cough, were not 
severe. This form constituted about two thirds of 
all cases. 
In the pulmonary form the onset was identical. 
5 Loomis and Walsh: Influenza Epidemic. 
There was, however, an early rapid drop in tem- 
perature to approximately normal on the second or 
third day. After a remission of a few hours, the 
temperature again rose, coincident undoubtedly 
with a localization of the infection in the smaller 
bronchi. An early drop in temperature was always 
Chart IV.--The rise in temperature after the remission simu- 
lates the fall in a gradual progressive manner. 
a cause for uneasiness as it was usually the fore- 
runner of the secondary pneumonic stage. This 
phase has frequently been spoken of as a complicat- 
ing pneumonia, but there are reasons for believing 
that it is but an extension of the specific infection. 
The temperature mounts rapidly to 103° or higher, 
the cough increases, the sputum which is usually 
6 Loomis and Walsh: Influenza Epidemic. 
thin and mucoid becomes blood stained, varying 
from a mere stain to a uniform pink. It is during 
this stage that the redness of the throat and mouth 
is most marked and typical. A persistent and dis- 
tressing nausea, with vomiting and diarrhea, sug- 
gests that this hyperemia may even extend to the 
gastrointestinal mucosa. These gastrointestinal 
symptoms, frequently accompanied by restlessness, 
headache and more or less delirium, gave to the1 
clinical picture an appearance of marked toxemia. 
The cough was troublesome and often so persistent 
as to greatly exhaust the patient. Cyanosis at this 
stage was the rule. It was usually slight but in the 
very severe cases was most intense. The pulse was 
comparatively slow, seldom going over no, except 
as a terminal event. The respiration varied from 
twenty to thirty-four, also showing but little in- 
crease, considering the temperature toxemia and 
pulmonary involvement. In more than one half of 
the cases in this small series the temperature fell by 
crisis. This crisis while not as definite as in the 
ordinary lobar pneumonia was nevertheless quite 
distinct. The average duration of this pneumonic 
stage was about six and one half days, varying from 
four to ten. 
In the fulminant, rapidly fatal cases, there was 
no initial drop, in fact the temperature rose 
abruptly, with but slight remissions to IO4°-IO5° 
and the cough, cyanosis, toxemia, and prostration 
were intense. Noticeable features in all cases were 
the remarkable loss of weight and the slow recov- 
ery of strength. 
Complications.-But two complications were ob- 
served. Catarrhal otitis media occurred once and 
empyema once. The latter developed on the eighth 
day, following the simple form of influenza. A 
pure culture of Streptococcus hemolyticus was 
found. 
Lung findings.-No pulmonary signs were evi- 
dent on the first day or two; when the symptoms 
continued unabated, evidences of acute bronchitis 
7 Loomis and Walsh: Influenza Epidemic. 
were manifested by sibilant and sonorous rales over 
both upper lobes. In the simple form no other signs 
were noted. On the development of the pulmonary 
form, no further signs were found for about two 
days, when feeble bronchovesicular breathing ap- 
peared in various parts of the lungs. In the two 
fatal cases this breathing became more marked 
with the progress of the disease until it was almost 
bronchial. In the first fatal case bronchovesicular 
breathing began over the left lower lobe but even- 
tually extended from the base to the clavicle; in the 
second fatal case it began over the left upper lobe 
and only later appeared in the lower. On the de- 
velopment of the bronchovesicular breathing, the 
percussion note became hyperresonant and only 
later impaired. In the first fatal case there was 
slight dullness on the left from the base to the fifth 
rib, twenty-four hours preceding death. At this 
time there was hyperresonance over the right lower 
lobe with feeble bronchovesicular breathing. The 
autopsy showed complete consolidation of the left 
lower lobe by coalesced patches of bronchopneu- 
monia and scattered patches of bronchopneumonia 
in the right. In the second fatal case bronchovesi- 
cular breathing began over the left upper lobe and 
here the first impairment of resonance was noted. 
A day later there was impairment of resonance 
from the base to the fifth rib and dullness from the 
fifth rib up. The day before death there was dull- 
ness from the base to the top of the lung. 
In one case at the height of the bronchopneu- 
monia there was impaired resonance with broncho- 
vesicular breathing from the fourth rib up on the 
left; in one, bronchovesicular over the right lower 
lobe; in one, bronchovesicular over several parts of 
the left lung; in one, bronchovesicular over both 
upper lobes; and in one there were present all the 
symptoms of bronchopneumonia, distressing and 
hacking cough, expectoration of pink tinged sputum 
for three or four days, high fever, marked toxemia, 
with no physical signs. '