We now come to the critical question whether the clinical symptoms reported for the Russian flu patients better fit an influenza virus infection or a trans-species infection with a bovine coronavirus or another infectious agent. To address this question, we are in the privileged position to have two comprehensive contemporary reports from Britain and Germany on the Russian flu pandemic. The British Parsons Report (see below) raised this point in discussing alternative agents such as dengue as potential agent, but rejected this possibility.

The British Parsons Report

In 1891 a 344-page ‘Report on the Influenza Epidemic of 1889–90 by Dr. Parsons with an Introduction by the Medical Officer of the Local Government Board’ appeared in London, summarizing the worldwide epidemiological data for the pandemic (Report on the Influenza Epidemic of 1889-90 – Great Britain. Local Government Board, Henry Franklin Parsons – Google Books; Further Report and Papers on Epidemic Influenza, 1889-92: With an … – Great Britain. Local Government Board – Google Books). It also presents data on the symptoms observed in patients from different institutions in England.

Hospital reports: Dr Low from St Thomas’s Hospital, London, wrote: ‘The invasion is sudden; …with acute pains in the back … often accompanied by vertigo and nausea, and sometimes actual vomiting of bilious matter. There are pains in the limbs and general sense of aching all over; frontal headache of special severity; pains in the eyeballs, increased by the slightest movement of the eyes; shivering; general feeling of misery and weakness, and great depression of spirits, … weeping; nervous restlessness; inability to sleep, and occasionally delirium. In some cases catarrhal symptoms are observed… eyes are injected; sneezing and sore throat; and epistaxis, swelling of the parotid and submaxillary glands, tonsilitis, and spitting of bright blood from the pharynx may occur. There is a hard, dry cough of a paroxysmal kind, worst at night. …There is often tenderness of the spleen. The temperature is high at the onset (100° F. in mild cases to 105° F in severe cases).’

Another physician noted: ‘The chief symptoms are coldness along the back, with shivering… severe pain in the head and eyes, …; pains in the limbs, … even in the fingers and toes; and febrile temperature, which may in the early period rise to 104° or 105° F. The patient feels excessively ill and prostrate, is apt to suffer from nausea or sickness and diarrhoea, and is for the most part restless, though often drowsy….the patient may recover in the course of three or four days. He may even have it so mildly that, although feeling very ill, he is able to go about his ordinary work. … patients have additionally some dryness or soreness of the throat, or some discharge from the nose, … accompanied by slight bleeding. … at a time when the patient seems to be convalescent, he begins to suffer from wheezing in the chest, cough, and perhaps a little shortness of breath, and before long spits mucus … tinged with blood…. Another complication is diarrhoea. Another is a roseolous spotty rash….’.

The Parsons report continues: ‘the sudden onset, rapid development of fever, and great and enduring nervous prostration is out of all proportion to the severity of the other general or local symptoms.’ It emphasizes ‘the small mortality from the disease’, but notes at the same time ‘the liability to relapses and dangerous pulmonary sequels’. ‘Catarrhal symptoms have been less prominent which led some observers to doubt whether the recent epidemic has been one of true Influenza’. Then: ‘the most common and urgent symptoms being the frontal headache and pain in the eyeballs, muscular pains in various parts of the body, and nervous depression’. ‘A rash, not unlike that of German measles, was seen in some cases, principally on the posterior aspect of the limbs’.

Reports from prison and asylum: Dr. Cowan, medical officer to the Pentonville Prison, is quoted in the report with: ‘Period of incubation: from one to seven days. General aspect: The patient looks ill and has a dull drowsy appearance. Prostration: Very marked, and a general desire to go to bed. Headache: Very severe, commencing at back of neck, and settling down into a severe frontal headache with post-orbital pains. Temperature averages 101°F, which only lasts about 24 h. Pain: Especially in head, back, and thighs. Sore throat noticed in a few cases. Diarrhoea in a few cases. Complications: Bronchitis with pain over sternum, but very little sputum. A dry hacking irritable cough, lasting about five days.’

The Parson report then continues with observations from 70 infected adult patients in an asylum of the insane in Edinburgh, published by the British Medical Journal on February 1st, 1890. The major symptoms were: great weakness (92%), frontal headache (88%), pain in limbs (84%), giddiness (81%), loss of appetite (78%), coryza (nasal discharge associated with common cold) (77%), bronchitis (77%), nausea (62%). Gastrointestinal signs were less frequent e.g. vomiting (38%) and diarrhoea (25%).

Observations resembling COVID-19: A number of observations described in the Parsons report resemble more characteristics of COVID-19 than those of influenza. Notable are:

Light affection in adolescents: ‘Among 177 cases in a girl’s school reported in the British Medical Journal of February 22nd, 1890 headache (98%), watery eyes (96%) and flushed face (80%) were the major symptoms. Among 85 adolescent boys frontal headache was the only symptom observed in more than 50% of the cases.’

Children are relatively spared: in the words of the Parsons report ‘It was by many considered that children were not so liable to contract Influenza as adults, but the large per-centage affected in some schools and training ships negatives this view. It seems, however, generally agreed that children who contracted Influenza did not have it so severely as adults, suffering less pain and being sooner convalescent.’

Age as risk factor for mortality: ‘Influenza was a disease especially fatal to elderly persons’.

Comorbidity as risk factor for mortality: ‘An attack of Influenza greatly tends to bring about or hasten a fatal termination if occurring in a patient who is already the subject of organic disease of the heart, phthisis pulmonalis (today: pulmonary tuberculosis), or pulmonary emphysema; and also, according to the statistics of Dr. Bertillon, diabetes or cerebral disease. It is also especially dangerous to persons advanced in life.’

Gender bias for morbidity: ‘Some medical men stated that more males suffered than females.’

Long haulers: ‘The long enduring evil effects of an access of Influenza in a large proportion of cases suggests that the materies morbi is only slowly extinguished in or eliminated from the system. Some subjects experience a weekly attack or relapse for many weeks after the primary access. It may take the form of great impairment of mental and physical power, or the more definite shape of vertigo or cardiac depression with general arterial relaxation necessitating recourse to the recumbent position.… Relapses …are of frequent occurrence; they occurred in 9% of the cases.’

Pathology: ‘the local phenomena may be the result of minute thromboses in the different organs of the body’ and ‘of the complications the most frequent are inflammatory conditions of the respiratory organs, as pneumonia, bronchitis, and pleurisy, and to these the mortality ascribed to it is chiefly due.’

Multisystem disease: ‘By many observers three forms of Influenza have been recognized, viz.: A. Nervous, B. Catarrhal, C. Gastric. These three forms have all been observed in cases occurring together under the same roof, and are evidently mere varieties of the same disease.’

Presymptomatic transmission: ‘It has been suggested by a German observer that the patient may be capable of communicating infection, while as yet only in the stage of incubation. If so, this would help to explain the rapid spread of the disease.’

Occasional symptomatic reinfection: ‘A case is recorded in the British Medical Journal of February 15th, 1890, in which a patient who had suffered from Influenza in France in December 1889, had another attack in England in January 1890.’

Lack of immune protection from previous influenza epidemic: ‘The persons now living who passed through the (influenza) disease in 1847 are of course comparatively few, but such persons have not been exempt from the present epidemic.’

The British Medical Journal reports

The 1889 pandemic was well covered in contemporary reports published in the British Medical Journal (Kousoulis and Tsoucalas, 2017). Eade (1891) reported on cases he treated in East Anglia. Some characteristics resemble more COVID-19 than classical influenza. He observed multiorgan affection ranging from the respiratory system (catarrh, dry spasmodic asthma, bronchitis) over gastrointestinal symptoms (nausea, vomiting, diarrhoea) to marked neurological symptoms. The latter comprised mental disturbances, dulled conditions of the brain, apathy and affections of sensory nerves. Skin affections were observed and included alopecia (loss of hairs). Pulmonary inflammation was the most frequent cause of death and affected the very old and the previously diseased. He noted frequent and severe nervous sequelae in cases from 1890. Regions severely affected in 1890 were nearly spared in 1891 suggesting a single agent and the development of herd immunity. When reporting on Influenza occurring in 1893–1894, the same British physician described a disease that corresponded to classical influenza with mortality peaks both in the very young and the very old persons and nearly exclusive lung affection with few other symptoms and no neurological sequels highlighting the different nature of the two diseases (Eade, 1894). Another British report reinforced the resemblance of the 1889–1892 epidemic with COVID-19 when noting that ‘the most common sequelae found have been nerve depression, neuralgia, headaches, and loss of taste and smell’ and describing pulmonary, intestinal and rheumatic forms, frequently mixed. The physicians also observed a ‘peculiar immunity of young children’ untypical for influenza (Anonymous, 1892). A combination of respiratory, gastrointestinal and neurological symptoms were also reported in Australia for residents of a mental disease asylum, where ‘tedious convalescence was almost general’ during the pandemic wave (Hay, 1892).

The Britannica entry

Further insight is provided by an Encyclopaedia Britannica entry on ‘Influenza’ published in 1911 (1911 Encyclopædia Britannica/Influenza – Wikisource, the free online library). At that time the phrase ‘Influenza simulates other diseases’ was coined (Clifford Allbutt) and it was reported that ‘cardiac attacks were common leading to the idea that a specific toxin for heart muscle was produced as well as a nervous toxin. In the Paris epidemic of 1890 the suicides increased 25%, a large proportion of the excess being attributed to nervous prostration caused by the disease.’ Dr Rawes treating in 1889–1890 influenza patients at St Luke’s hospital in London, is quoted with ‘insanities traceable to influenza melancholia is twice as frequent as all other forms of insanity put together. Other common after-effects are neuralgia, dyspepsia, insomnia, weakness or loss of the special senses, particularly taste and smell, abdominal pains, sore throat, rheumatism and muscular weakness. The feature most dangerous to life is however the special liability of patients to inflammation of the lungs.’

The German ‘Verein für Innere Medicin’ Report

When considering that in 1889 the germ theory of infectious diseases had not yet won over the theory of miasma, where foul air released from fissures in the soil opened up by earthquakes were argued to be at the base of epidemics, a report collected by the German association of internal medicine issued in 1892 at Berlin appears strikingly modern in its approach (Leyden and Guttmann, 1892 https://collections.nlm.nih.gov/catalog/nlm:nlmuid-64820270R-bk). This association designed a questionaire comprised of 15 subject areas regarding observations with patients from the Russian flu epidemic in Germany. The survey was sent to 20 000 medical doctors over all regions of Germany and 6000 returned detailed answers which were then systematically evaluated by subcommittees of this association according to symptom complexes. The 189-page report accompanied by numerous maps can be summarized as follows (translation from the authentical text by the authors are marked by ‘…’, explicative terms in parantheses by the present authors).

Cardiovascular observation: ‘Affection of the heart particularly in elderly and obese subjects could be life threatening. Many patients report a feeling of constriction of the thorax and precordially localized anxiety. Pericarditis and endocarditis was repeatedly mentioned. Rheumatic disease was noted as complications. The most interesting complication affects the vascular bed because this has not previously been seen in other epidemics. Phlebitis and thrombosis was frequently observed in the recovery phase, even deadly cases of sinus thrombosis occurred. Striking were cases of thrombosis in arteries.’

Respiratory observations: ‘Nearly without exception coryza (rhinitis) was observed, associated with lacrimation and sneezing attacks; epistaxis (nose bleeding) was very frequent as was local swelling of lymph nodes. Pharyngitis and tonsillitis frequently led to laryngo-tracheitis where the feeling of an irritation in the larynx caused coughing. The irritation descends from the bronchi into the smallest bronchiole. Initially there is a dry cough which later culminates in paroxysm of coughing. Dyspnea (shortness of breath) is frequently observed.’

Pneumonia: ‘This epidemic was not only characterized by the high frequency of pneumonia, observed in 5 to 10% of all infected subjects, but particularly by the observation of croupous pneumonia (defined by fibrinous matter in the air vesicles of the lung). The mortality in patients with pneumonia was very high and ranged from 15 to 26%. Death occurred by lung edema and heart paralysis. Bronchopneumonia started with shivering and slow temperature increases. Pneumoniae were most frequent in the elderly and persons with weak constitution. In middle-aged people pneumonia occurred without fever. Effusion into the pleura cavity was observed in 12 to 20% of the cases. The most important complication was cerebral meningitis in the convalescence phase which was not observed in any of the previous epidemics. Sequels were reported for people with cardiac diseases and diabetes. Rare cases of hemorrhagic lung infarcts with embolic material from upper leg veins were described. Tuberculosis was exacerbated by the infection. Preterm delivery was reported.’

Gastro-intestinal observations: ‘The GI tract was affected in nearly all patients, more severe gastrointestinal symptoms were however only observed in a quarter of all cases. The disturbance was manifold and could persist for 4 weeks particularly in children. In 18% of subjects only the stomach, in 15% only the intestine was affected. Loss of appetite was accompanied by strange changes in taste perception. The patients reported either complete loss of taste or abnormal taste perception describing as bitter or putrid taste impressions. Vomiting occurred in 34%, diarrhoea in 34% of the patients and 15% suffered from both vomiting and diarrhoea. Both symptoms were associated with a shorter disease course. 5% of the cases showed a haemorrhage of the intestinal mucosa.’

Neurological observations: ‘Neuralgic pain and prostration is prominent and for 92% of the patients neurological complaints dominated the disease. Patients noted mostly headache, and less frequent back and muscle ache. A quarter of the patients was incapable resuming their usual activity even without showing other symptoms of illness. Vertigo, sleeplessness, fainting and neuralgic pain in cranial nerves (trigeminus) were reported with a frequency ranging from 5 to 14% of the patients. Many reported substantial disturbances of smell and taste perceptions. After the acute phase, impaired memory was observed interpreted as exhaustion psychosis. General exhaustion after the infection was frequent and many patients needed several weeks to regain their former strength.’

Skin: Half of the patients showed a minor, quickly disappearing exanthema (skin eruption in certain viral or coccal infections). Petechia (pinpoint skin bleeding) and skin haemorrhage was observed and bleeding from the mucosa, particular the nose, was frequent.

Multisystem disease: The physicians noted several forms of disease manifestations during the pandemic which ‘they distinguished as (i) nervous, (ii) respiratory, (iii) gastric and (iv) rheumatic forms. They observed in Germany a geographically distinct representation of these four disease manifestations.’

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