INFLUENZA EPIDEMICS SINCE 1893.
In this section of our report we will describe with as great accuracy as
our sources of information will permit, and in as great detail as space
will allow the events which have led up to the epidemics of 1918–20 and
the various phases of the epidemics themselves. Points of similarity
with previous epidemics will be made obvious; the differences, when of
significance, will be described and studied in detail.
OCCURRENCE SINCE 1893.
Attempts even today to determine when and where influenza has prevailed
in the world since the great pandemic of the last century are met with
great difficulties. There are several reasons for this, chief among
which is the absence of definite characteristics by which the disease
may be recognized. The isolated solitary case baffles positive
diagnosis. Nearly every year there are reports in the literature of
small outbreaks in institutions or communities in which the clinical
picture is that of epidemic influenza. As a rule the conclusion has been
in these cases that because the bacteriologic findings did not show a
predominance of Pfeiffer’s bacillus the epidemic was not true influenza.
This is particularly true in the outbreaks in which the streptococcus
predominated. Today our views concerning the bacteriology have changed
distinctly, and I believe it is safe to say that the predominance of a
streptococcus in a local epidemic in no way rules out influenza, and
that the only criteria by which we may judge are the clinical picture
and the evidence of high infectivity, together with the epidemiologic
characteristics of the local outbreak.
_Period 1893–1918._—A review of the medical literature between 1889 and
1918 gives one a certain impression which may be summarized as follows:
Between 1890 and 1900 the disease was in general more highly prevalent
in most localities than at any time during the preceding thirty years.
At no time during this decade did the annual death rate from influenza
in England and Wales fall to anywhere near the figures that had
prevailed consistently between 1860 and 1889. Between 1900 and 1915
there was a gradual diminution, but still not to the extent that had
prevailed previous to 1889. Since 1915 there appears to have been a
gradual increase. During the entire period there has been difficulty in
distinguishing between the disease in question and other respiratory
tract infections, particularly coryza, sore throat, tonsillitis, and
bronchitis. Many of the local epidemics which appear probably to have
been true influenza have had associated with them a high incidence of
sore throats. We describe this as sore throat, rather than tonsillitis,
because the clinician remarks that although the throat is sore there is
little if any demonstrable inflammation of the tonsils.
Chart VIII published by Sir Arthur Newsholme, showing the death rate per
million of population from influenza in England and Wales gives some
idea of the prevalence of the disease in the first part of the
interpandemic period in those countries. It should be remarked that the
record is for deaths from influenza only.
For records in this country it is convenient to refer to the death rate
in the State of Massachusetts; first, because the records in that State
have been carefully kept for a long period; and second, because
influenza has been carefully studied in this State during both epidemics
by two most competent epidemiologists. For the period preceding 1889 we
quote herewith from Abbott:
“For the past 45 years or more, or during the period of registration
which began with the year 1842, no epidemic of influenza has prevailed
within the State to such an extent as to have manifested itself in any
serious manner in the annual lists of deaths. An examination of the
registration reports for each year since 1842 shows that in no year were
recorded more than 100 deaths from this cause; the highest number from
influenza in a single year (92) occurred in 1857, and the least number
(8) in 1884. The average annual number of deaths from this cause
reported in the State for the period 1842 to 1888 was 38. The average
number during the first half of this period was greater than that of the
last half, especially when considered with reference to the increase of
population. From these statistics of nonepidemic influenza between the
years 1842 and 1888 it appears that its greatest prevalence, or rather
the years in which the mortality from this cause was greatest, were also
years of unusual mortality from pneumonia, and in some instances from
bronchitis.”
Frost has charted the death rate per 100,000 from influenza and from all
forms of pneumonia in Massachusetts by month, from 1887 to 1916. From it
he concludes that the epidemic of 1889–1892 developed in three distinct
phases, the first culminating in January, 1890, the second in April and
May, 1891, and the third in January, 1892. The mortality was higher in
1891 than in 1890, and still higher in 1892, while in 1893, although
there was no distinct epidemic, the pneumonia mortality for the year was
even higher than that of 1892. Frost remarks that this corresponds to
the experience in England, and that it apparently represents the general
experience in other countries (see charts IX and X).
CHART VIII.
[Illustration:
Death rates per million from influenza in England and Wales from 1845
to 1917. (_Newsholme._)
]
CHART IX.
[Illustration:
Monthly death rates per 100,000 from influenza and from pneumonia in
Massachusetts from 1887 to 1916. (_Frost._)
]
CHART X.
[Illustration:
Monthly death rates per 100,000 from influenza and pneumonia in three
cities of the United States from 1910 to 1918, inclusive. (_Frost._)
]
In the absence of comparable statistics for Massachusetts in 1917 and
1918, Frost has studied for those years certain other localities,
particularly Cleveland, San Francisco and New York City. The mortality
in all of these places, as well as in Massachusetts, was fairly regular
from 1910 to 1915, but in December of the latter year and January of
1916 there occurred in New York and Cleveland a sudden sharp rise in
mortality. This was not shown distinctly in the San Francisco curve, but
it was a rise which was almost universal and synchronous over the entire
registration area. It is of interest as indicating the operation of some
definite and widespread factor, and suggesting in this group of diseases
an epidemic tendency which is perhaps, as Frost remarks, not
sufficiently appreciated. In January of 1916 he found that influenza was
reported to be epidemic in twenty-two states, including all sections of
the country. The epidemic was very mild. In the early spring of 1918
there was another sharp rise, which we shall discuss in greater detail
later.
_Increase in 1900–1901._—Reference to Frost’s chart for Massachusetts
shows that there was also a rise in the curve around 1900. At this time
influenza was quite widely disseminated. Early in 1901 the Marine
Hospital Service made a canvass of all the states and several foreign
countries to determine the epidemic prevalence of influenza. The results
of the canvass were published in the Public Health Reports. The records
lack the detail, particularly in the description of clinical symptoms,
that is desirable in arriving at an identification, but the universal
agreement from all individuals reporting, in the comparatively high
morbidity and remarkably low mortality, together with the widespread
distribution, and the duration of the local epidemic leaves little doubt
as to the identity.
Influenza was reported present in October of 1900 in Los Angeles,
Milwaukee and New Orleans. In November it became prevalent in Toledo and
Cincinnati and in New York City. In December the disease was present in
Chicago, Albany, Philadelphia, San Francisco, Denver, Baltimore, Grand
Rapids, Columbus, O., Portland, Me., Detroit, Albuquerque and Omaha. In
January it was reported in New Haven, Boston, Washington, D. C.,
Indianapolis, Louisville, Ky., Wilmington, Del., Portland, Ore., and
Juneau, Alaska.
Although the disease was mild, in some localities a high proportion of
the population was attacked. Thus in New Haven it was estimated that 10
per cent. developed the disease, and in Los Angeles 20 per cent., while
in Wilmington, 40,000 were estimated to have become ill. In certain
small towns in Texas the incidence was especially high. In Pittsburgh,
Texas, ten per cent.; Laredo, 15 to 20 per cent.; Hearne, 50 per cent.;
and El Paso, 50 per cent. were attacked. The duration of the epidemic in
most localities was from four to six weeks.
Thus we see that in October, November and December of 1900 and January
of 1901 there was a widespread epidemic affecting all parts of the
United States. Many additional records in the Public Health Reports
coming from small towns have not been included in this summary.
At the same time an attempt was made to determine the prevalence in
foreign countries and letters were sent to the various United States
Consulates. It was discovered that the disease was mildly epidemic in
Denmark in October, in Berlin in November, in Cuba, British Columbia,
Ontario, Egypt, Paris, Mexico and the West Indies in December; in
Flanders, Porto Rico, Honolulu, in January of 1901; in Malta in
February, 1901; and in London and Ireland in March of that year. The
following countries reported that they had no influenza at the time:
Windward Islands, Jamaica, Bahamas, Brazil, India, Colombia, Costa Rica,
Ecuador, Honduras, Persia, Philippine Islands, Spain, Switzerland. The
disease was reported as being not of epidemic prevalence in the
following localities: Marseilles, Paris, Bremen, Hamburg, Mainz,
Stuttgart, Bristol, London, Liverpool, England as a whole, Scotland,
Amsterdam, Naples, Constantinople.
Reports from Switzerland and from Brazil stated that there had been no
influenza since the pandemic period 1889–1893. The death rate per
100,000 in Glasgow from influenza for 1896 was recorded as six; for
1897, twelve; for 1898, fifteen; 1899, twenty-two and for 1900,
twenty-seven.
The disease was present in Lima, Peru in March, 1900, and at Malta in
the same month. In Prague it was stated that ten per cent. of the
population had been attacked in the winter of 1901. In Sivas, Turkey,
fifty per cent. of a population of 50,000 were estimated to have been
taken ill within the winter months. It was reported from Valencia,
Spain, that there had been four or five visitations of influenza since
the preceding pandemic, each recurring invasion presenting a milder and
less expansive form than its predecessor. Very few deaths had been
recorded as directly due to influenza, but an increased mortality
followed the epidemics. In normal times the average mortality was ninety
deaths per week. After a visitation of influenza the number had
increased to as much as 160 per week. The population numbered 204,000.
_Period from 1901 to 1915._—Between 1900, with its wide distribution of
a very mild influenza, and 1915, there is very little mention of
epidemic prevalence of the disease. References which appeared in the
Public Health Reports during the interval are characterized chiefly by
their brevity, and by the absence of descriptive detail. They should
nevertheless be included.
In October of 1901 there was some increase of the disease in the
Hawaiian Islands, 110 cases being reported on the island of Kauai.
At the same time, C. Williams Bailey reported a mild form of influenza
existing in Georgetown, S. C., which was first considered to be hay
fever in consideration of the presence of the rice harvest season, but
which was finally decided, after careful investigation, to be true
influenza.
On July 21, 1902, the U. S. Consul at Canton, China, telegraphed that
influenza “was almost epidemic, plague sporadic in Canton.”
In 1903 the disease was reported as apparently prevalent at New Laredo,
Texas.
Surgeon Gassaway, of the Marine Hospital Service, reported from
Missouri, December 14, 1903, as follows: “There is a very decided
increase in the number of cases of influenza in this vicinity. Two have
been admitted within the last few days to this hospital, and several
cases have appeared among the patients under treatment. In these cases
the onset is sudden and the disease appears principally, at least at
first, to be confined to the nose and throat.”
Measles and influenza were reported prevalent in Barbados, West Indies,
during the month of December, 1904.
Sturrock describes a quite typical local epidemic in a British
institution in 1905.
Influenza was epidemic in Guayaquil and various other places in Ecuador
during the months of June and July, 1906.
Selter speaks of a true local epidemic of a disease clinically
resembling influenza which occurred in 1908 and extended over the
territory from France to the Rhine.
Hudeshagen mentions having examined bacteriologically cases of influenza
in the year 1914.
Ustvedt relates his experience at the Ullevaal Hospital up to September,
1918. Since 1890 there had been cases reported every year from the high
marks of 10,461 cases in Christiania in 1890 and 5,728 in 1901 to the
lowest figure, 138 in 1906. “The cases listed as influenza in the last
few years may have been merely a catarrhal fever. This is the more
probable as the cases were restricted to the winter months, while
influenza usually occurs at other seasons.”
Jundell believes that influenza is endemic at Stockholm, Sweden,
hundreds of cases being reported there each year. During the years
1912–1919 Pfeiffer’s bacillus has been found in ten per cent. of those
cases in which the diagnosis seemed certain.
A current comment in the Journal of the American Medical Association in
1912 remarks that epidemics of coryza, sore throat, and bronchitis
usually have been called influenza or grip because of the characteristic
contagiousness and the infectivity, the persistence of the symptoms, and
the tendency to prostration and mental depression. But this diagnosis
has not been satisfactorily confirmed by bacteriologists. An epidemic
according to the Journal, which occurred in Boston and which was called
sore throat, was studied by Richardson and others. They traced the
contagion to a streptococcus which apparently was spread by means of
milk. Müller and Seligman had recently carried out a study of an
influenza epidemic among children in Berlin and concluded that the
causative organism was a streptococcus, differing so much from the
ordinary germ that they used the term “grip streptococcus.” Davis and
Rosenau, according to the comment, had made a bacteriologic study of a
recent epidemic of sore throat in Chicago, and had demonstrated as the
exciting agent a streptococcus of peculiar characteristics, which in
many respects resembled the organism described by Müller and Seligman.
The Journal noted that these three epidemics occurring during the years
1911 and 1912 in widely separated communities were all caused by the
streptococcus, and cautioned against the proneness to call all such
epidemics grip. Today the predominance of the streptococcus would not
necessarily rule out influenza in our minds.
In the winter of 1913, C. L. Sherman had occasion to study carefully
fourteen cases of so-called influenza in the vicinity of Luverne,
Minnesota. Bacteriologic smears and cultures were made from the throat
and sputum in all cases. Bacillus influenzae was found in two of the
fourteen; pneumococcus in four and streptococcus in all. Tubercle
bacilli were found in one case. The onset of the disease was invariably
abrupt. The fever in all cases ranged between 101° and 104°; symptoms
indicative of infection of the upper respiratory tract were always
present. There was more or less sore throat in all. There was either
cough at the onset or else it appeared within 48 hours. Headache was
complained of by twelve of the fourteen; pains in the back and in the
limbs by thirteen, and nervous symptoms by six. Prostration out of all
proportion to the fever and other symptoms prevailed. Two developed an
otitis media and the streptococcus was isolated from the purulent
discharge in both cases. One patient had a complicating empyema, and one
an acute arthritis. Sherman also concluded that we are prone to call too
diverse diseases influenza.
Walb stated in 1913 that at Bonn during the preceding years there had
been numbers of cases of a febrile affection which seemed to be typical
influenza, but for which the pneumococcus appeared to be responsible.
They were never able to isolate the influenza bacillus, and according to
their statement the Hygienic Institute at Bonn, as well as that at
Berlin, had not “encountered an influenza bacillus within the preceding
ten years.”
C. T. Mayer described in 1913 a case of influenza in Buenos Ayres which
is of particular interest in view of one of the symptoms, cyanosis,
which was so prominent a feature in 1918. This appears to have been an
isolated case. The diagnosis wavered between miliary tuberculosis and
pneumonic plague, because of the high fever and intense cyanosis, with
nothing to explain the cyanosis on the part of the heart. There were
signs of severe congestion of both lungs, and notable enlargement of the
spleen. Bacteriologic examination was negative except for the presence
of Bacillus influenzae and Micrococcus catarrhalis. The patient
subsequently improved rapidly, and the lungs were entirely normal after
thirty days, thus ruling out the other two diseases.
A London letter to the Journal of the American Medical Association dated
February 5, 1915, runs as follows:
“Since the outbreak of the war the public health has been remarkably
good, but the record is now being threatened in the case of London, at
any rate, by an epidemic of influenza.
“The gastric symptoms which distinguished last year’s epidemic are
absent. The disease is most infectious. Whenever it has seized the
individual it has usually run through the entire household.
“Whole offices have succumbed, and as the mildness of the attack lures
the sufferer to continue his normal occupation, the disease has a full
opportunity of extending. A large number have resulted in
pleuro-pneumonia; otherwise the chief symptoms are headache, fever,
tonsillitis.”
Telling and Hann describe another clinical diagnosis of influenza, the
diagnosis being concurred in by Sir James Goodhart and Sir Clifford
Allbutt. The onset was absolutely sudden at a supper party on November
10, 1912. The patient had a slight rigor, and was compelled to go to
bed. In the night he had a longer and more severe rigor, with a
temperature of 103°. On the following morning he dressed, but another
chill sent him back to bed with a temperature still 103°, pulse 110,
regular, and remarkably dicrotic. There was no cough and no sore throat.
Another chill occurred in the evening. On November 12th the patient had
two chills, the temperature remaining steadily at 103° to 104°. The
patient complained much of nausea but did not vomit. On November 13th
the temperature remained up, there was no chill on this day; the spleen
was large and easily felt for the first time. On the 14th note was made
that there was no headache. On the 15th, 16th and 17th the temperature
began to fluctuate. On the 18th there were two severe rigors, and by the
19th the temperature suddenly fell to normal, with drenching sweat.
Throughout there was nothing to suggest pneumonia, and typhoid fever
appears to have been successfully ruled out.
An epidemic of influenza which prevailed in the city of Pittsburgh,
Pennsylvania, from December to February of 1907 and 1908, has been
described by J. A. Lichty. He says that the epidemic was as widespread,
though probably not quite as severe, as the pandemic of 1889. Whole
families, including servants and all associated with the household, were
afflicted in rapid succession. The onset was sudden and severe, the
usual symptoms of pain, all over, being most pronounced. The temperature
did not go unusually high, nor did it seem to be in accord with the
severity of the symptoms when the patient took to his bed. In typical
cases the attack lasted from two to three or four days. Peculiar to this
epidemic seemed to be the general complaint of sore throat. Upon
examination the throat rarely showed any other evidence of an abnormal
condition than a rather dark cyanotic blush, which was most intense over
the tonsils and faded out over the roof of the mouth. This was rarely
associated with any swelling or fever. Sinusitis and otitis media seem
to have been the two most frequent complications. The disease appeared
to be particularly fatal for chronic invalids. It was highly contagious.
Many of those physicians who were frequently exposed to the disease fell
victims.
At the same time C. H. Jones described an epidemic of the same disease
in Baltimore. The symptoms were described as headache, backache,
limb-ache, with a slight elevation of temperature, seldom more than
102°. Catarrhal symptoms developed secondarily and were not so prominent
a feature as in former epidemics. There were some gastric symptoms,
usually consisting of vomiting and nausea. Jones quotes no statistics,
but feels sure that the infection was more extensive than at any period
since 1895.
Coakley and Dench describe throat and ear complications as they saw them
in New York. From this we may assume that the disease was present at the
same time in New York City.
The following chart, derived from the U. S. Vital Statistics Report
shows the increase in the death rates from influenza in 1900 and 1901;
that of 1907 and 1908, and finally an increase to 26.4 per 100,000 in
1916, which reflects the epidemic beginning in the latter part of 1915:
_Influenza and Pneumonia Mortality in the United States Registration
Area for Each Year Since 1900._
═════════════════╤═════════════════════════════════════════════════════
Year. │ Annual death rates per 100,000.
─────────────────┼─────────────────┬─────────────────┬─────────────────
„ │ Pneumonia. │ Influenza. │ Combined
│ │ │ diseases.
─────────────────┼─────────────────┼─────────────────┼─────────────────
1900│ 158.6│ 22.8│ 181.4
1901│ 133.5│ 32.2│ 167.7
1902│ 124.7│ 10.1│ 134.8
1903│ 122.6│ 18.5│ 141.1
1904│ 136.3│ 20.2│ 156.5
1905│ 115.7│ 18.8│ 134.5
1906│ 110.8│ 10.3│ 121.1
1907│ 120.8│ 23.3│ 144.1
1908│ 98.8│ 21.3│ 120.1
1909│ 96.3│ 13.0│ 109.3
1910│ 147.7│ 14.4│ 162.1
1911│ 133.7│ 15.7│ 149.4
1912│ 132.3│ 10.3│ 142.6
1913│ 132.4│ 12.2│ 144.6
1914│ 127.0│ 9.1│ 136.1
1915│ 132.7│ 16.0│ 148.7
1916│ 137.3│ 26.4│ 163.7
─────────────────┴─────────────────┴─────────────────┴─────────────────
At best our information for these years is unsatisfactory. It is greatly
to be desired that individuals who have access not only to the current
medical literature, but also to the vital statistics and other records
for all countries possessing reliable records, and who are versed in the
newer mathematical methods of demography, establish definitely the
influenza prevalence and distribution during these interpandemic years.
The difficulty in this work is that mortality statistics are unreliable
and morbidity statistics are lacking.
_Influenza in 1915–1916._—Until the end of 1915 there was no widespread
distribution in the United States similar to that of 1900 and 1901, but
at that time there developed a widespread epidemic in this country of
similar or possibly slightly greater severity than that of fifteen years
previously. Reference to the last table will show that during 1916 the
annual death rate from influenza as reported in the United States Vital
Statistics reached the rate of 26.4 per 100,000. According to V. C.
Vaughan the literature of that time shows that this epidemic originated
in the West, first attracting attention at Denver, and gradually spread
over the country.
Dr. Dublin of the Metropolitan Life Insurance Company gives the
following table in which the deaths from influenza and pneumonia during
the months of December, 1914, and January, 1915, are compared with
deaths from the same cause during the months of December, 1915, and
January, 1916:
═══════════════╤═══════════════════════════╤═══════════════════════════
Name of city │ Deaths reported as due to │ Deaths reported as due to
│ influenza. │ pneumonia.
───────────────┼─────────────┬─────────────┼─────────────┬─────────────
„ │ In 1915–16. │ In 1914–15. │ In 1915–16. │ In 1914–15.
───────────────┼─────────────┼─────────────┼─────────────┼─────────────
Baltimore │ 57│ 12│ 219│ 101
Cincinnati │ 81│ 2│ 105│ 84
New Orleans │ 97│ 44│ 35│ 29
New York │ 494│ 62│ 2,067│ 1,207
Philadelphia │ 324│ 62│ 564│ 272
Providence │ 38│ 3│ 31│ 31
───────────────┼─────────────┼─────────────┼─────────────┼─────────────
Total │ 1,091│ 185│ 3,021│ 1,724
───────────────┴─────────────┴─────────────┴─────────────┴─────────────
Dublin states that the Industrial Department of the Metropolitan Life
Insurance Company, covering the entire country and embracing ten
millions of people, had deaths in the periods above mentioned, as
follows:
In December, 1914, and January, 1915, the number of deaths
attributed to influenza was 165
While in the corresponding months of 1915–1916 the deaths
attributed to influenza were 957
The deaths attributed to pneumonia in December, 1914, and
January, 1915, were 1,468
While the number of deaths attributed to the same cause in
December, 1915, and January, 1916, were 2,563
Coffey and others have reported an epidemic of influenza at Worcester,
Mass. during the first three weeks of January, 1916. During the first
three weeks of January, 1915, there were reported in that city
twenty-two deaths from respiratory diseases, making a total of 14.9 per
cent. of the total deaths. In the same period of 1916 there were
reported ninety-three deaths from acute respiratory diseases in the same
population.
Two of the more complete descriptions of the epidemic of the year
1915–16 are those by Mathers, and by Capps and Moody. Mathers reports
that: “During the winter of 1915–1916 the United States was visited by a
severe epidemic of acute respiratory infections which resembled in every
detail the great epidemic of 1890. This outbreak was apparently first
noticed in the Middle Western States, and it spread rapidly over the
entire country, taking a heavy toll of human life. December and January
were the months in which these infections were most prevalent, and the
epidemic had almost completely lost its impetus by March, 1916. During
the height of this epidemic in Chicago, sixty-one cases of the disease
were studied bacteriologically, and the results form the basis of this
paper.”
Mathers found hemolytic streptococci in forty-six instances, in all of
which they predominated. Green producing streptococci were found thirty
times, with one pure culture, and pneumococci thirty times with four
pure cultures. Staphylococci were isolated in fifty cases; Micrococcus
catarrhalis in six, and Friedländer’s bacillus in one case. The
influenza bacillus was found in only one instance, and then in small
numbers. The majority of the patients were studied early in the course
of the disease, and in the earliest, hemolytic streptococci were almost
constantly found, especially in the throat. In the atypical pneumonia
which followed many of the attacks of grip, hemolytic streptococci
predominated. In none of these was the Bacillus influenza found.
Mathers reported that coincident with the epidemic among humans there
was an epizootic of so-called influenza among horses. The symptoms are
very similar to that of the disease among humans. He isolated a
streptococcus as the predominating organism in the horses. The
streptococci from human and equine sources, although similar in many
characteristics, differed widely in pathogenicity, and seemed to be
highly parasitic for the specific hosts.
Capps and Moody found that in man most cases began rather abruptly, with
coryza, pharyngitis, laryngitis, or bronchitis.
“The chief complications were inflammation of the accessory sinuses of
the head, and bronchopneumonia, the latter being responsible for most of
the fatalities. None of these symptoms taken alone would justify the
distinctive name of grip. But the widespread and almost simultaneous
onset of this fairly uniform symptom group and the rapid cessation of
the epidemic after a few weeks reminded physicians generally of the
great grip pandemic of 1889–1890. This resemblance was further
strengthened by the unusual prostration lasting days or weeks after even
mild attacks. The older practitioners can recall no similar epidemic
during the twenty-five years intervening between 1890 and this year. The
numerous epidemics of septic sore throat have all been entirely
different in their symptomatology, and all were restricted to certain
localities. The term “grip,” therefore, seems justified from a clinical
standpoint.
“The public health reports offer evidence of an unusual prevalence of
pneumonia in the larger cities. Nicolas calls attention to the fact that
the incidence of grip was greatest in those cities in which the
mortality from pneumonia was most strikingly increased.”
Capps and Moody found that as a rule the white blood counts in the
individuals sick with influenza were 10,000 or less. A number showed
true leucopenia. Less frequently there was a leucocytosis up to 15,000
or higher.
_Influenza between 1916 and 1918._—Zinsser cites Dr. George Draper, who
believes that he observed at Fort Riley in the winter of 1917 epidemic
cases of influenza. He believes that for Europe too there is evidence
that influenza was endemic during the years preceding the great
outbreak, and that a number of minor epidemic explosions had occurred in
the years just preceding 1918:
“MacNeal who has investigated military reports particularly, states that
small epidemics occurred in the British Army in 1916 and 1917. A chart
constructed by him from the American Expeditionary Force reports shows
that a considerable rise in reported influenza cases took place in
November and December, 1917, and in January, 1918, gradually declining
toward spring. MacNeal, compiling the data available in the office of
the Chief Surgeon, A. E. F., states that the influenza morbidity
reported per 100,000 for succeeding months in 1917, were as follows:
July 321
August 438
September 404
October 1,050
November 1,980
December 2,480
“Robertson, who studied many of the secondary pneumonias which came to
autopsy at this time found an unusual type of lobular pneumonia in which
Pfeiffer bacilli were frequently found. In many of these cases the
organisms could be obtained from the nasal sinuses and antra. Similar
findings were reported by British bacteriologists (Hammond, Rolland and
Shore, and Abrahams, Hallows, Eyre and French), who studied the cases
that occurred in the reports by Austrian physicians in reference to
outbreaks of typical influenza on the Austro-Russian front early in
1917.
“There seems little doubt, therefore, that for some years before the
pandemic of 1918 influenza was endemic in many parts both of Europe and
of America. As early as 1915–1916 Frost finds evidences of limited
epidemic outbreaks in the United States. During the winter immediately
preceding the true beginning of the pandemic small outbreaks occurred
among the allied troops in France, the British troops in England and
probably among American troops gathered in home concentration camps as
well. MacNeal in a summary of the conditions prevailing among American
troops in France concludes that epidemic influenza in that country
originated from the endemic foci there existing, and that the disease
was probably carried from Europe to the United States by shipping. The
former assumption; namely, that the epidemic occurrence of the disease
may have been due to the fact that an enormous and concentrated newly
introduced material of susceptibles may have been lighted into flame at
the numerous endemic smoulders, may well be correct. The latter,
however, concerning the transportation of the disease from Europe to
America may justly be questioned. For, in the first place, Frost’s
studies have shown that prepandemic outbreaks were quite as frequent in
the United States as in Europe during 1915 and 1916, and, though we have
no proof of this, there is reason to believe that influenza was
prevalent in concentration camps during 1917.”
Carnwath, after remarking that the epidemic began in the British Army in
France in April, 1918, says that according to the reports of the
Influenza Committee of the Advisory Board this was not the first time
that Pfeiffer’s bacillus had appeared in the armies. On the contrary, it
had frequently been found in cases of bronchopneumonia, especially
during the winter of 1916–1917. It is doubtful, however, whether much
importance, from the epidemiologic point of view, attaches to these
sporadic findings of the Pfeiffer bacillus.
Influenza was reported in the year 1917, but this year, as well as the
epidemic of 1916, becomes involved in a determination of the date of
onset of the great pandemic of 1918.
THE PANDEMIC OF 1918.
The date and site of onset of the great pandemic are subjects concerning
which there is no conclusive information. There have been small
outbreaks of clinical influenza with epidemic tendencies at one place or
another during nearly all of the intervening years since 1889. In all of
them the question is open as to whether they were true influenza, and
also assuming that some were true influenza, how many of them should be
so included. There are some who believe that the increase of morbidity
following the measles epidemic in the United States Army camps in the
winter of 1917–18 is genetically associated with the great pandemic. In
short, there is no one point in the last few years at which we may say
that influenza which had previously been non-existent started at a focus
and spread throughout the world.
It follows from the experience of 1889 that we should at least attempt
to find an endemic focus and to follow the progression of the disease.
It is safe to say that once having become pandemic the disease spread as
it did thirty years previously. Experience in this country, where the
autumn spread began in the New England States and continued West and
South; knowledge of the late spread to remote localities; the fact that
the disease first appeared in England, etc. in sea coast towns; the
introduction of the influenza into new countries at seaport towns, after
the arrival of infected ships, all coincide well with the past history.
But which of the several local epidemics of the preceding years was the
direct progenitor of the great pandemic? In order to follow more clearly
the development of the facts we will record here the various hypotheses
that will come up for consideration as to the site of origin of the
disease.
1. Influenza is endemic in some one locality, such as Turkestan in Asia,
from which place the disease spreads throughout the earth at intervals,
after having acquired in some way greatly increased virulence. The local
outbreaks of interepidemic times are not due to the virus which causes
the great pandemics and should be called pseudo-influenza in contrast to
influenza vera. Following the pandemic it is true, however, that for a
succession of years local outbreaks occur, due to the pandemic virus
which has been left deposited in small endemic foci. These disappear in
the course of a few years.
2. The second hypothesis is similar to the first, except that in it is
considered the possibility of there being more than one endemic focus,
at least two, one in the old world and one in the new. Although
Leichtenstern believed in the first hypothesis he did not deny the
possibility of the second.
“There have been in the past several well described influenza epidemics
limited to North America. Furthermore true pandemics have occurred at
the same time in North America and in Europe. We can suggest the
hypothesis that there is a permanent endemic focus, just as in central
Asia and Russia, existing in the southern part of North America. The
following facts concerning the last pandemic period favor this idea.
“As early as May, 1889, influenza began in Athabasca (British North
America) and in the summer of 1889, in Greenland. It is especially
interesting to hear of an extensive influenza epidemic which in the
middle or toward the end of December, 1889, broke out in the Northwest
Territory of British North America, in Manitoba, in the Island of
Vancouver, similar to that in the east of Canada and Quebec. A spread of
the epidemic, which attacked Boston and New York on December 17th, to
the above territories, far away and connected by very poor
transportation facilities, is certainly improbable, especially in
consideration of the time at which the two epidemics occurred.
“We are told that the invasion and the outbreak of influenza in these
vast territories occurred at practically the same time at such widely
separated places as Fort MacLeod, Saskatchewan, Prince Albert and other
military posts, and furthermore in isolated Indian camps and tribes
between which there was little or no communication.
“These facts also indicate that we are considering primary endemic
pandemics analogous to the one which broke out in July, 1889, in Central
Asia.”
3. The virus of influenza is more or less uniformly distributed
throughout the world. We may say that it is endemic in many localities,
as is the case with the meningococcus. Quite frequently in one locality
or another the virus acquires increased virulence and causes a small
local epidemic which may even spread to adjoining territories. It is
possible that the virus in two or more separated localities may become
more invasive simultaneously, thus causing widely separated and
unrelated outbreaks. As a rule the virulence does not become so great as
to cause a true pandemic, but at rare intervals, usually of decades, or
thereabouts, the epidemic virus becomes so greatly enhanced, perhaps
from passage to new territory and through non-immune individuals, that
it eventually commences on its wild career around the earth. Perhaps the
_pandemic_ variety usually comes from one particular locality among the
many endemic spots. Perhaps always from the same locality or perhaps at
times even simultaneously from many different ones. It is possible even
that an increased virulence develops simultaneously in all localities.
This third hypothesis develops into a discussion as to whether the small
interpandemic epidemics are true influenza or some other disease.
Again, Leichtenstern, although he does not favor it, recognizes the
possibility of this theory:
“Whether the small local epidemics reported by Kormann in Coburg in 1878
and by O. Seifert in Würzburg in 1883 are the same as the true epidemic
influenza is at present uncertain. Some of the complications, such as
swelling of the neck glands, and especially frequently parotitis,
purpura, scurvy, indicate that the epidemic in Russia, in 1856–1858,
reported by Kasin, was not the true influenza.
“When W. Zülzer writes in 1886 of an epidemic in Berlin in which many
thousands of individuals were attacked, the question might arise, is
this the same influenza which three years later passed through the
entire world and which in Berlin was believed by the same physicians to
be a new disease?
“The evidence is better in the case of the epidemic reported by von den
Velden in 1874–75. First, because of the complication with pneumonia and
especially because at the same time the disease sprang up in several
places in France, South Germany and the Rhine Provinces. It is very
doubtful whether epidemics described in 1855 and 1862 in Iceland, in
1870 in Philadelphia, in 1875 in Scotland, in 1876 in the Fiji Islands,
in 1887 in several places of England, in October, 1889 in Natal, in
November, 1889 in Jamaica and Prince Edward Island, was the true
influenza, even though the complications of pneumonia in the last named
epidemics favor this assumption. As regards the influenza epidemic which
attacked specially the school children of Pleshey and Great-Waltham and
from which fifty per cent. became ill in November and December, 1889,
whereas the pandemic was known to have begun there in January, 1890—the
high percentage of school children that were attacked renders the
conclusion that this was influenza very doubtful.
“It is an entirely different matter concerning the last epidemic in
which the epidemiologic compilations, based on retrospective diagnoses
suggest that in many places of Germany the ‘first case’ of even small
epidemic outbreaks was observed as early as the summer and autumn of
1889; in other words, several months before the outbreak of the true
pandemic in December.”
Leichtenstern believed that the so-called catarrhal fever and epidemics
of “cold” which some have been accustomed to call grip or influenza are
not the true disease, although he admits that there is no pathognomonic
sign by which the diseases may be differentiated. He expected that
search for the influenza bacillus which had recently been discovered
would enable investigators to determine by its presence or absence
whether or not these local epidemics are true influenza.
This, of course, would depend on the proof that the influenza bacillus
is the cause of the disease. If the many local influenza outbreaks which
Hirsch has collected in his exhaustive historical tables are the same
disease as true influenza, then the picture of influenza must be
considered as rather protean. Leichtenstern adds that this is a
possibility which from present information we cannot deny. He writes:
“If such is the case we must give the following epidemiological
definition of influenza: Influenza is a specific, infectious disease
usually occurring epidemically which, however, is endemic over the
entire earth, as indicated by outbreaks of cases, and which, after years
and decades have passed, breaks out in epidemic proportions. It is
recognized nearly every year in one or another place on the earth where
it becomes epidemic. From time to time from some point or center, or
from several points, as for instance simultaneously in the old and new
world, and for reasons unknown to us, an enormous increase in virulence
of the specific virus occurs and with it a great increase in the
contagiousness of the disease. Those are the times when influenza
spreads in mighty epidemics over wide stretches of land and portions of
the earth, or over the whole earth. Our common epidemic influenza or
grip, occurring practically isolated or in very small outbreaks, belongs
to the same type of disease as the pandemic variety, but is due to a
mitigated form of the causative organism, one of decreased virulence and
of shorter viability.
“_Provisionally, however, we will hold_ until the proof has been
obtained by bacteriological methods that influenza nostras and influenza
pandemica are two entirely different diseases, just as are cholera
nostras and asiatica. Accordingly, we will divide the diseases
designated as influenza in the following way:
“1. Influenza vera, caused by the Pfeiffer bacillus.
“2. The endemic-epidemic influenza vera which arises from the germ
remaining after the spread of the influenza pandemic and which is caused
by the same germ, the bacillus of Pfeiffer. The duration of this endemic
state of influenza vera may last years in single localities.
“3. The endemic influenza nostras, or pseudo-influenza or catarrhal
fever, commonly called grip, a disease sui generis. The germs causing
this disease are at present as little known as are those of cholera
nostras.”
Parkes, in 1876, recognized these possibilities: “The exact spot has not
been made out. Two opinions prevail. First, one focus; second, many
foci. Each nation, in turn, attributes the disease to its neighbor and
from the names so given one can follow the direction of the epidemic.”
Noah Webster believed that in 1698, 1757, 1761 and 1781 it originated
first in America. Hirsch believed that some of the epidemics had
probably originated in North America.
We find then that after the pandemic of the last century the same
epidemiologic questions had arisen that have come into such prominence
during the present period. As a rule those who have quoted the
epidemiologists of 1890 to 1900 have mentioned the first hypothesis and
have failed to allude to the fact that the other two were considered. So
we see that the subject was by no means settled even at that time, and
that if we should discover that the 1918 pandemic cannot be traced to a
single endemic focus our results will not be absolutely contradictory to
those of the last century.
Returning to a consideration of the period 1916–1918, we observe from
reference to Frost’s diagram that in the spring of 1918 there was a
sharp and general rise in mortality from influenza and pneumonia. Frost
reports that in the larger cities on the Atlantic seaboard this increase
occurred generally during January, February and March, when pneumonia
mortality normally reaches its maximum. The increase was not so evident
in all these cities as it was in New York City. In the rest of the
country, especially in the Central and Western States, the increase
occurred in April, a month during which pneumonia mortality is generally
on the decline, and was sufficient to constitute an unmistakable
departure from the normal. The increased mortality rate extended quite
generally into May and in some areas still longer. This is the first
increase after 1916 that is pictured in the mortality statistics for the
country at large.
There are some who believe that they saw influenza in mild form in the
United States army in the year 1917. V. C. Vaughan has investigated this
possibility and from a study of the sick and wounded charts decided that
there was no relation between influenza and the pneumonia which was
prevalent in 1917, and which usually was secondary to measles, being
caused by the streptococcus in the majority of localities. The lack of
association between influenza and pneumonia in 1917 and the direct
association in 1918 is well brought out by a comparison of the figures
in the two following charts, prepared by V. C. Vaughan:
_Pneumonia as a Sequel to Respiratory Diseases._
(All troops in United States in 1917.)
─────────────────┬─────────────────┬─────────────────┬─────────────────
│ │ No. of cases │ Per cent. of
Primary diseases.│ No. of cases. │ followed by │cases followed by
│ │ pneumonia. │ pneumonia.
─────────────────┼─────────────────┼─────────────────┼─────────────────
Measles │ 47,573│ 2,075│ 4.37
Scarlet Fever │ 1,966│ 54│ 2.75
German Measles │ 8,982│ 39│ 0.43
Bronchitis │ 41,233│ 20│ 0.049
Influenza │ 32,248│ 19│ 0.059
Meningitis │ 1,027│ 13│ 1.27
Tonsillitis │ 43,021│ 7│ 0.016
Pulmonary │ 6,799│ 6│ 0.088
tuberculosis │ │ │
Laryngitis │ 4,633│ 2│ 0.043
Diphtheria │ 1,163│ 1│ 0.086
Mumps │ 21,725│ 0│ 0.000
Pharyngitis │ 8,096│ 0│ 0.000
─────────────────┴─────────────────┴─────────────────┴─────────────────
_Influenza and Pneumonia in Last Four Months of 1918._
Number of cases of influenza 338,343
Number of cases of influenza followed by pneumonia 50,700
Number of deaths from influenza-pneumonia 17,700
Stallybrass, who has studied the influenza and pneumonia deaths in
Liverpool, England, since the 1889 pandemic, states that in every year
there had been reflected in the curves evidence of periodic increase in
deaths from influenza and pneumonia, and he states that from 1914 onward
there has been a progressive increase in the annual number of influenzal
deaths with the single exception of 1917.
It becomes evident that we cannot with the information at hand find any
one locality in which the disease was prevalent sufficiently ahead of
the pandemic and to the exclusion of other localities, so that we might
determine accurately the site of origin. The next step will be, then, to
discover as accurately as possible the date at which various communities
were first definitely attacked by the great pandemic, and to search out
the locality first affected.
DATE OF FIRST INCREASED PREVALENCE IN VARIOUS LOCALITIES.
From table II which gives the earliest recorded dates of increased
prevalence in different localities, we can gain a fairly accurate idea
as to the direction and manner of spread of the disease during the
pandemic. Influenza was first noticed in the United States early in
March, 1918. By the end of the month it had become more disseminated in
very mild form over many of the States east of the Mississippi and a few
West of that line. The following month the disease appeared in France.
In the American Expeditionary Forces in France it first appeared at the
base ports which were receiving troops from the United States. During
this month the disease had reached the allied Western front, the German
front had become infected and probably the disease had started on its
travel inward into enemy country. In May the disease was reported
present in Scotland, Spain, Greece and Egypt. In June England became
infected, as also Switzerland, Germany, Austria and Norway. In this
month the disease had reached as far as South America and India. In
China, on the 15th of June, there was reported an epidemic of a disease
resembling dengue which affected fifty per cent. of the population in
Chefoo and Shanghai. This disease may well have been influenza. During
July the disease had spread through Germany, appearing according to
German reports in the cities toward the West earlier than in Berlin and
other more Eastern cities, including Vienna. In July the disease was
present in other countries of Europe and was again reported in China and
India.
TABLE II.
_The spread of influenza in 1918._
═══════════╤════════════╤═════════════╤═══════════════╤════════════════
Month. │ Date. │ Country. │ City. │ Authority
│ │ │ │ quoted.
───────────┼────────────┼─────────────┼───────────────┼────────────────
March │ │_China_ │ │McNalty,
│ │ │ │ Carnwath.
│ │Japanese Navy│ │McNalty,
│ │ │ │ Carnwath.
│ │_Japan_ │ │Jour. Am. Med.
│ │ │ │ Assn.
│ │ │Civilian │
│ │_France_ │ Population at│MacNeal.
│ │ │ Chaumont │
│ 5│_United │ │
│ │ States_ │ │
│ │Kansas │Camp Funston │Opie.
│ │Missouri │Kansas City │V. C. Vaughan.
│ │Illinois │Chicago │Frost.
│ │Ohio │Columbus │V. C. Vaughan.
│ │Michigan │Detroit │V. C. Vaughan.
│ 18│Georgia │Camp Greenleaf │V. C. Vaughan.
│ │ │Atlanta │V. C. Vaughan.
│ 28│S. Carolina │Camp Sevier │W. T. Vaughan.
│ 30│Kansas │Haskell │Public Health
│ │ │ │ Reports.
───────────┼────────────┼─────────────┼───────────────┼────────────────
│ │_United │Various points │Public Health
April │ │ States_ │ from Norfolk │ Reports.
│ │ │ to Louisiana │
│ │Mississippi │Camp Shelby │V. C. Vaughan.
│ │Georgia │Camp Hancock │Forbes and
│ │ │ │ Snyder.
│ 30│California │San Quentin │Stanley.
│ │ │ Prison │
│ │_France_ │ │Netter.
│ │ │ │Chauffard.
│ │ │ │Messary.
│ │ │ │Longcope.
│ │ │Brest (American│
│ 1│ │ Expeditionary│V. C. Vaughan.
│ │ │ Forces) │
│ │ │British │
│ │ │ Expeditionary│Carnwath.
│ │ │ Forces │
│ │ │Allied Western │Public Health
│ │ │ Front │ Reports.
│ 1│ │German Western │Gins.
│ │ │ Front │
───────────┼────────────┼─────────────┼───────────────┼────────────────
May │ │_France_ │Chaumont │Zinsser.
│ │_Scotland_ │Glasgow Dunlop,│Carnwath.
│ │ │ │Office
│ │_Spain_ │Madrid │ International
│ │ │ │ d’Hygiène
│ │ │ │ Publique.
│ │_Greece_ │Athens │Filtzos.
│ │ │ │Teissoniere,
│ │_Macedonia_ │French Army │ Beguet and
│ │ │ │ Jolly.
│ │ │Egyptian │
│ │_Egypt_ │ Expeditionary│Benjafield.
│ │ │ Forces │
│ │_Italian │ │MacNeal.
│ │ Navy_ │ │
───────────┼────────────┼─────────────┼───────────────┼────────────────
June │ │_England_ │Portsmouth │Carnwath.
│ 15│ │Birmingham │Public Health
│ │ │ │ Reports.
│ 1│_Switzerland_│Zürich │Office
│ │ │ │ International
│ │ │ │d’Hygiène
│ │ │ │ Publique.
│ 1│_Germany_ │Frankfurt, A. │Deutsche. med.
│ │ │ M. │ Wehnschr.
│ 3│ │Strasbourg │Rose.
│ │ │ (Alsace) │
│ 25│ │Bonn │Koepchen.
│ At the end │ │{Berlin │Deutsche. med.
│of the month│ │ {North & │ Wehnschr.
│ │ │ South Germany│
│ Late│_Austria_ │Vienna │Bohm.
│ 15│_Norway_ │Christiania │Public Health
│ │ │ │ Reports.
│ 15│_China_(?) │Chefoo │Public Health
│ │ │ │ Reports.
│ 16│_Brazil_ │Santos │Public Health
│ │ │ │ Reports.
│ 22│_India_ │Bombay │Public Health
│ │ │ │ Reports.
│ │_Porto Rico_ │ │Atiles.
│ │Philippine │ │Hernando
│ │ Islands │ │
│ │ │ │
───────────┼────────────┼─────────────┼───────────────┼────────────────
July │ 1│_Germany_ │Dresden │Schmorl.
│ │ │ │Office
│ │_Italy_ │ │ International
│ │ │ │ d’Hygiène
│ │ │ │ Publique.
│ 13│_Sweden_ │Malmo │
│ │ │Gothenburg │Frost and
│ │ │ │ Sydenstricker.
│ Late 27│_Netherlands_│Flushing │Public Health
│ │ │ │ Reports.
│ │_China_ │Chungking │Public Health
│ │ │ │ Reports.
│ │_India_ │Calcutta │Malone.
───────────┼────────────┼─────────────┼───────────────┼────────────────
August │ │_India_ │Punjab │Jour. Am. Med.
│ │ │ │ Assn.
│ 3│_West Indies_│Guadeloupe │Public Health
│ │ │ │ Reports.
│ │_United │Boston │Second Spread.
│ │ States_ │ │
───────────┼────────────┼─────────────┼───────────────┼────────────────
September │ │_Denmark_ │ │Frost and
│ │ │ │ Sydenstricker.
│ 11│_Republic of │ │Public Health
│ │ Salvador_ │ │ Reports.
│ 16│_Honduras_ │ │Frost and
│ │ │ │ Sydenstricker.
│ 25│_Bermuda_ │ │Frost and
│ │ │ │ Sydenstricker.
│ 30│_Jamaica_ │ │Frost and
│ │ │ │ Sydenstricker.
│ │_Mexico_ │Santa Cruz │Frost and
│ │ │ │ Sydenstricker.
│ 21│_Canada_ │Victoriaville │Frost and
│ │ │ │ Sydenstricker.
│ │ │Quebec │
│ │ │Hamilton │
│ 30│_Portugal_ │Lisbon │Public Health
│ │ │ │ Reports.
│ 28│_Morocco_ │Tangier │Frost and
│ │ │ │ Sydenstricker.
│ 14│_South Africa│ │Frost and
│ │ Union_ │ │ Sydenstricker.
│ 16│_Senegal_ │Dakar │Public Health
│ │ │ │ Reports.
│ 16│_Sierra │Freetown │Public Health
│ │ Leone_ │ │ Reports.
│ │_Korea_ │ │Schofield.
│ │_United │West and South │
│ │ States_ │ from Boston │
───────────┼────────────┼─────────────┼───────────────┼────────────────
October │ Early│_Alaska_ │ │Governor’s
│ │ │ │ Annual Report.
│ 1│_Russia_ │Archangel │Frost and
│ │ │ │ Sydenstricker.
│ │_Peru_ │Lima │Soldan.
│ │_Uruguay_ │Montevideo │Frost and
│ │ │ │ Sydenstricker.
│ 25│_Venezuela_ │ │Frost and
│ │ │ │ Sydenstricker.
│ 11│_Guatemala_ │ │Frost and
│ │ │ │ Sydenstricker.
│ 12│_Costa Rica_ │Limon │Frost and
│ │ │ │ Sydenstricker.
│ 26│_Colombia_ │Begota, │Frost and
│ │ │ Barranguilla.│ Sydenstricker.
│ │ │Cartagena, │Frost and
│ │ │ Peru. │ Sydenstricker.
│ 9│_Cuba_ │Camagney, │Frost and
│ │ │ Nuevitas │ Sydenstricker.
│ 22│_Azores_ │ │Public Health
│ │ │ │ Reports.
│ 18│_Canary │ │
│ │ Islands_ │ │
│ 19│_Madagascar_ │ │Frost and
│ │ │ │ Sydenstricker.
│ 17│_Australia_ │ │Frost and
│ │ │ │ Sydenstricker.
│ 19│_New Zealand_│ │Frost and
│ │ │ │ Sydenstricker.
│ │_Hawaii_ │Honolulu │Frost and
│ │ │ │ Sydenstricker.
───────────┼────────────┼─────────────┼───────────────┼────────────────
November │ │_British │ │Rose.
│ │ Guiana_ │ │
│ │_Dutch │Paramaribo │Frost and
│ │ Guiana_ │ │ Sydenstricker.
│ 22│_Samoa_ │Apia │Frost and
│ │ │ │ Sydenstricker.
│ │_Arabia_ │Aden │Frost and
│ │ │ │ Sydenstricker.
│ │_Iceland_ │ │Erlendsson.
───────────┼────────────┼─────────────┼───────────────┼────────────────
December │ │_Paraguay_ │Paraguay, │Frost and
│ │ │ Asuncion │ Sydenstricker.
│ │_Dominican │La Plata, │Frost and
│ 19│ Republic_ │ Puerto Plata,│ Sydenstricker.
│ │ │ Santo Domingo│
│ │_Lapland_ │ │Macklin.
│ 8│_Society │ │Frost and
│ │ Islands_ │ │ Sydenstricker.
│ 3│_Tonga │ │Frost and
│ │ Islands_ │ │ Sydenstricker.
│ │_Fiji │ │Frost and
│ │ Islands_ │ │ Sydenstricker.
───────────┴────────────┴─────────────┴───────────────┴────────────────
During its course through Europe influenza had developed a greatly
heightened virulence and toward the end of August it again appeared in
the United States apparently traveling in a reverse direction from that
of its first spread and, entering the country at Boston, it spread to
the West and South until the entire country was covered. The West Indies
were invaded early in August and in the same month the disease had
spread through India as far as the Punjab. In September the epidemic
continued through the West Indies, attacked Mexico and Canada, and had
attained such remote localities as the South Africa Union, Senegal and
Korea. In October the spread was particularly distributed through South
America, and in this month again remote localities such as Alaska, New
Zealand, the Hawaiian Islands, Australia, and Madagascar were reached.
Islands, which although not very remote, were isolated except for the
arrival of occasional ships, such as Cuba, the Azores and the Canary
Islands, were first reported attacked in October. In November the spread
continued throughout the world, and among the more remote localities
should be mentioned Samoa, Arabia, Iceland. In December, Lapland, the
Society Islands and the Fiji Islands were invaded (see Chart XI).
CHART XI.
[Illustration:
Cinematogram showing the spread of influenza in 1918 from a
presumptive primary focus in the United States.
]
It is particularly of interest to follow the spread of the disease in
Europe. Perhaps the chief characteristic is the distribution equally to
the north and south of France, a country which appears to have been
invaded early. In May it spread to Scotland and to Spain, Greece and
Egypt. In June the spread was in three directions, to England and Norway
on the North, to Switzerland, Germany and Austria on the East, and again
into Spain and Italy on the South.
The correctness of the foregoing description of the spread of influenza
depends first, upon the accuracy of the authorities quoted, and
particularly upon our having discovered the earliest report for each
country. The author believes that the information as obtained for the
United States represents nearly the true state of affairs, and that the
error present is negligible. The information obtained for France is
based upon the statements of excellent investigators, Netter, Chauffard
and Massary, for the French population, and MacNeal, Zinsser and
Longcope, for the American Expeditionary Forces. Here the statements
agree both for the military and for the civil population that there was
no widespread influenza in France much before April 1st. Also, the
author feels that the information for England and Scotland is
authoritative and will not later be changed. It is based particularly
upon the excellent reports by Carnwath, who has investigated the subject
in great detail. The excerpts from the German literature, although not
abundant, are practically unanimous in agreeing as to the date of
invasion in Germany. The reports from the remaining countries of Europe
have been less abundant, and frequently the author has been forced to
rely upon a report by only one individual; but while the date may be in
error, yet the month of occurrence is probably correct.
For other continents, Asia, Africa and South America, the reports as far
as they go appear reliable, but it is impossible to prove that at an
earlier date there was not a very mild epidemic in some one of these
localities, similar to the earlier epidemic in the United States, which
escaped detection. It is particularly important, in view of the 1889
experience, that we obtain if possible fuller information on the
earliest time of the appearance of the disease in China and other parts
of Asia, and that we determine whether there was a spread from that
continent to America previous to March, 1918.
Several factors have added considerably to the difficulty in tracing the
site of origin of the 1918 epidemic and its direction of spread. The
principal of these have been the speed of modern travel, the character
of modern commerce, and the existence of a state of war. The channels of
the commerce of today radiate nearly from all points to all other points
of the civilized world. No longer are there a few preeminent lanes of
travel, such as there were in 1580 when the epidemic spread clearly from
Constantinople to Venice and on to Hungary and Germany, finally finding
its way to Norway, Sweden, Denmark and Russia. The war has made it
difficult to know accurately the date and direction of spread in enemy
countries. We have practically no information, except that in the public
press, from Russia and the Balkan States. By October of 1918 the severe
form of the disease had become prevalent in every continent, and by
December it had reached the farthest islands of the Southern Pacific
ocean.
The apparent difference in the direction of spread between 1889 and 1918
makes comparison of rapidity difficult. But if we take as our starting
point the time at which each epidemic became prevalent in commercial
centers of Europe and the time at which it finally reached localities
well off the usual paths of commerce we will see that there is some
difference, the disease spreading more rapidly in the recent epidemic,
but that the difference is no greater than could be accounted for by the
more modern means of communication. From April, 1918, when the disease
appeared in France, to October, when it was reported in Madagascar, is
six months. From October, 1889, with the disease prevailing in
Petrograd, to July, 1890, when it appeared in Madagascar, is nine
months. It required seven months after the disease became epidemic in
France this time for it to appear in Iceland, and nine months in
1889–90.
The earliest recorded epidemic of influenza in the United States in the
spring of 1918 (but which was not recognized to be such until later)
appears to have been that at Camp Funston, described by Opie and his
associates as having appeared in that Camp March 5th. The epidemic swept
quickly throughout the Camp and spent itself as rapidly. A second wave
appeared in April and in May a third, both of which were almost entirely
limited to newly drafted men brought into camp subsequent to the
preceding outbreaks. Correlated with each of these three outbreaks was a
period of increased incidence of pneumonia and bronchitis, frequently
occurring in influenza cases. These complicating diseases were prevalent
in the organizations attacked by the influenza and maintained the same
relation to the length of service of the men affected.
The next report of influenza in the United States was from the
Oglethorpe camps, beginning about March, 18, 1918. Within two weeks
every organization in Camp Forrest and the Reserve Officers Training
Camp was affected. After about three weeks the epidemic subsided
rapidly. Fourteen hundred and sixty-eight cases were sent to the
hospital out of a total strength of 28,586. It is estimated that 2,900
cases had occurred. The clinical symptomatology and the epidemic
characteristics were described in detail.
On March 28th the author had occasion to observe a similar epidemic at
Camp Sevier, South Carolina, which appears to have attacked a smaller
proportion of the troops in camp, but which showed the same
epidemiologic picture. A note in the Public Health Reports states that
on March 30, 1918, the occurrence of eighteen cases of influenza, of
severe type, from which three deaths resulted, was reported at Haskell,
Kansas. This is the earliest report we have been able to find concerning
the disease in civil communities. That for Chicago was practically
contemporary. The Commissioner of Health of Chicago states in his
special report on the autumn epidemic, that in March, 1918, distinct
epidemics resembling influenza were observed in certain portions of that
city.
According to Public Health Reports, fevers of an undetermined nature
were reported during April and May at various points from Norfolk to
Louisiana. “An examination of the records and reports of the physicians
who had treated these cases leads to the belief that these fevers were
mainly influenza of mild type.” It is possible, however, that all cases
reported were not of the same disease, and in one locality in Louisiana
dengue may have occurred.
Fleisher states that during the latter part of March and early part of
April, 1918, there occurred at Camp Wadsworth an epidemic of measles and
practically concomitant with it an epidemic form of bronchopneumonia
associated with empyema. During this time there were some 200 cases of
measles and twenty-one cases of bronchopneumonia or empyema in which a
hemolytic streptococcus was the causative agent. He makes no mention of
any epidemic of influenza either in mild or severe form, occurring at
this period.
Forbes and Snyder reported that during the month of April, 1918, a
highly contagious, but comparatively mild infection of the respiratory
tract was epidemic in Camp Hancock. Several thousand men in the command
were infected, but relatively few were ill enough to be sent to the
hospital. The only fatal case occurred early in the epidemic, and it was
the observations made in this case which prompted the study made by
Forbes and Snyder.
The fatal case had the subjective symptoms familiar to influenza. The
physical findings were similar to those occurring in influenza in the
later epidemics. The leucocyte count was 4,300. A blood culture showed
in twenty-four hours a heavy growth of small non-motile, gram-negative
bacilli which the authors concluded to be Bacillus influenzae. The
leucocyte counts made at five hour intervals on a later date were
respectively, 3,400, 2,200 and 2,300. A second blood culture taken on
April 10th, a day later, also showed a pure culture of the same
organism. The leucocyte count had risen to 5,600. At necropsy a
confluent bronchopneumonia was found. There was no pleural effusion and
the other viscera showed nothing remarkable. Bacillus influenzae was
recovered from cultures taken from the lung and spleen.
Throughout this epidemic the clinical picture of the disease was
characteristic. Nearly every patient gave as the initial symptoms
backache, headache, slight cough or sore throat. Conjunctivitis and a
marked injection of the soft palate were noted in ninety per cent. of
the cases. In addition, a slight or moderate general adenopathy was
often observed. The face was flushed and in a few cases the skin of the
thorax presented a mild erythema. In three cases a provisional diagnosis
of scarlet fever was made until the blood count showed a leucopenia.
Leucopenia was characteristic of all cases.
During the early April epidemic at this camp, nasopharyngeal cultures
showed an organism resembling Bacillus influenzae in seventeen out of
thirty-three cases, but the identity of the organism was not established
by subcultures. In ten cases in which sputum examinations were made,
Bacillus influenzae was found in only four; streptococci were present in
six. Blood cultures on twenty consecutive non-fatal cases, only one of
which was complicated by bronchopneumonia, were all negative.
V. C. Vaughan reports that at Camp Shelby, Hattiesburg, Miss., there was
in April a division of troops numbering about 26,000. An epidemic of
mild influenza struck this camp in April, 1918, and within ten days
there were about 2,000 cases. This included not only those who were sent
to the hospitals, but also those who were cared for in barracks. This
was the only division that remained in this country without change of
station from April until the fall of 1918. During the summer this camp
received 20,000 recruits. In October, 1918, the virulent form of
influenza reached this camp. It confined itself almost exclusively to
the recruits of the summer, and scarcely touched the men who had lived
through the epidemic of April. Not only the 2,000 who had the disease in
April, but the 24,000 who apparently were not affected, escaped the fall
epidemic.
Vaughan also remarks that in March and April of 1918 there was an
unusually high death rate from pneumonia in Atlanta, Ga., Kansas City,
Mo., Detroit, Mich., and Columbus, Ohio, while in the autumn epidemic
these cities suffered rather less than the average. In view of the
experience at Camp Shelby he reasons that there was probably mild
influenza in these cities in March and April of 1918. It may be stated
that in the mortality statistics for 1918, the abnormally high death
rates for respiratory diseases during March and April were present
throughout the registration area of the United States.
The first reports that we have been able to discover concerning
influenza on the Pacific Coast are for the month of April. Stanley
reports three successive waves of epidemic influenza at San Quentin
Prison, Cal. The first began on April 30, 1918, with the entrance into
the institution of a prisoner who was sick on admission.
Following the disease in its possible spread to the next continent we
are inclined to conclude that it was carried to France with the great
body of men traveling to that country from the United States. MacNeal
and Longcope both report that in the first outbreak in the American
Expeditionary Forces the earliest recorded epidemic appeared about April
1, 1918, in a rest camp near Bordeaux. It reached its height April 22d
and ceased May 5th. According to V. C. Vaughan a mild epidemic of
influenza and pneumonia prevailed at Brest and in that vicinity from
April 1st to July 31st, 1918. During this time fifty cases of influenza,
twenty-six of which developed pneumonia, with two deaths were admitted
to the United States Naval Base Hospital at Brest. The disease was
prevalent at the same time among the French civil, military and naval
groups in the same locality. We see then that in the American
Expeditionary Forces at any rate the disease first occurred in two base
ports receiving troops from the United States. In May, 1918, a second
outbreak was reported from Tours, which lasted from May 1st to May 24th
and affected 117 persons. Zinsser reports an epidemic at Chaumont during
May and from this time until July more or less extensive epidemics
occurred throughout the entire American Expeditionary Forces.
Longcope remarks that the disease was likewise prevalent at this time
among the French population and in parts of the British Army. The
Influenza Committee of the British Advisory Board determined that in the
first British Army the disease became prevalent around May 18th.
Carnwath states that in the British Army in France the epidemic began by
a few local outbreaks in the first and second Armies in April and May,
1918. Later it spread to the first, third and fourth Armies and affected
a very large proportion of the troops.
Small describes two epidemics of influenza in one of the largest General
Hospitals of the British Expeditionary Force in France. He says that the
first wave began in April, 1918.
The fact that MacNeal, as we have previously recorded, believed that
there was influenza in France in 1917, must not be overlooked. Those
earlier cases were scattered and did not so far as we know occur in the
form of small epidemics. Even if these were true influenza it is
reasonable to assume that they were sporadic cases and were not
genetically associated with the epidemic spreading from America and
daily increasing in virulence, which we are now following. MacNeal
concludes that epidemic influenza in France originated from the endemic
foci existing there, and that the disease was probably carried from
Europe to the United States by shipping. The author’s opinion regarding
the first direction of spread is that the reverse condition was the
actual process. Zinsser likewise holds the latter view.
A most important observation made by MacNeal is that French physicians
practicing among the civilian population were perfectly familiar with
the disease when it appeared at Chaumont in April, 1918, that they
designated it as La Grippe, and stated that it had been extensively
prevalent in the civilian population of Chaumont from March 15th to May
15th, 1918. These observations of influenza occurring in France at
almost the same date as the first outbreaks in the United States is a
matter of great interest. It has also been stated by McNalty and by
Carnwath, who quotes Kabeshima and Lee, that the disease was prevalent
in epidemic form in China and Japan in March, 1918. We have here three
foci from which the disease may have primarily originated. There are two
possibilities; first, that it originated in all three foci (and perhaps
others), and spread to all parts of the world from each; second, that
the virus, distributed throughout the world, acquired high virulence in
all three localities, causing small epidemic outbreaks, but that the
virus from only one of these places finally became so exalted as to
cause the pandemic. Did the _pandemic_ disease originate simultaneously
in France, in China and in the United States? One fact seems certain,
that the influenza which attacked our troops in Europe was influenza
imported from the United States. We have seen that it first appeared in
the American Expeditionary forces at the base ports. Alberto Lutraria,
Health Commissioner of Italy, has reported that the disease was brought
to that country from America. A point of significance is the fact that
during March and April there was an unusually large troop movement from
the United States to the American Expeditionary Forces.
MacNeal says: “The suggestion that the epidemic was introduced from
America is supported by the fact that it appeared at a time when large
numbers of Americans were arriving in Europe, which is indeed an
outstanding feature correlated in time with the onset of the epidemic.”
According to the report of the Influenza Committee, the disease was
first seen in epidemic form in April and May in the British Armies in
France, but that was not the first time that Pfeiffer’s bacillus had
appeared within the armies. It had frequently been found in cases of
bronchopneumonia, especially during the winter of 1916–17. Carnwath
remarks that it is doubtful whether much importance from an
epidemiologic point of view attaches to these sporadic findings of the
influenza bacillus. In an outbreak of measles and rubella—complicated by
purulent bronchitis—which attacked men belonging to the draft of troops
from New Zealand between January 1st and March 8th, 1918, the bacillus
influenzae was present in twenty-four of the forty sputa examined, and
was grown in culture in twenty-one cases. Sellards made somewhat similar
observations on measles patients at Camp Devens.
Concerning the French population, Chauffard, Messary and Netter, all
remark that the first cases in France developed in April with possibly
some cases before that time, and that there were undoubtedly cases in
the German Army in April.
We see then that by April the disease has been transferred to France and
is prevalent in the various armies. It is natural to assume that the
battle front would present no great obstacle to the spread of the
disease into the German Army. Gins remarks that the disease was present
on the German West front among the troops as early as April, 1918, and
that it spread from there more rapidly to the South than to the North.
During the month of May we observe the spread of the disease to Great
Britain, where Carnwath, who has made an exhaustive study of the spread
in Great Britain, believes that it was imported by the troops from
France. Its first recorded appearance in Glasgow was in May. Dunlop, in
reporting the successive epidemics in Scotland, observed that in
addition to the three well marked epidemics there was a mild one
recognizable in Glasgow in May, and that in that city the death rate
rose from 14.1 to 20.1, and the weekly number of deaths from pneumonia
and bronchitis from 36 to 107.
In England the disease first attracted attention in June, appearing
first in the coast towns, chiefly at the beginning among the military
and naval forces. The civilian population was severely affected only
later. The ports which were earlier attacked were Portsmouth,
Southampton and Liverpool. Inland towns suffered more severely later.
In the same month that the disease broke out in Scotland it appeared in
Spain. The Inspector General of Health in that country reported that an
epidemic of the disease began at Madrid in the last half of May, 1918,
at a period when there was an unusually large gathering of people in the
city. Within a short time it had spread rapidly through all the
provinces. The increase in death rate became marked on the 27th of May
and reached its peak on the 31st, at which time the rate was twice that
of the average annual death rate for that period of the year. During the
following week there was some oscillation around the peak and then the
curve fell away. The epidemic was particularly severe at Madrid,
Badajoz, and Seville. It was mild at Barcelona.
MacNeal remarks: “In Spain the disease appeared in epidemic form about
the middle of May and this outbreak received great publicity, sufficient
to lead to the popular appellation of Spanish influenza. The very rapid
and extensive spread of the disease in Spain would indicate that it had
been introduced from without rather than transformed from the endemic
state in that country. This also appears to accord with the view of
those who have studied the epidemic in Spain.”
Filtzos reports that influenza first appeared in Greece toward the end
of May, 1918. The symptoms were slight and the people who were attacked
suffered for three or four days with fever, accompanied by nervous
symptoms. It was called at the time “Spanish Fever”. Beginning with
September the epidemic became worse and caused a considerable rise in
mortality. Complications with bronchopneumonia appeared. The decrease in
incidence began toward the middle of December, 1918.
According to Benjafield, the pandemic first commenced in the Egyptian
Expeditionary Force in May, 1918, but the maximum incidence was not
reached until September and October. The cases during the earlier period
of the epidemic were on the whole mild in type and of short duration,
only a very small proportion being complicated by bronchopneumonia. The
epidemic continued from November, through February, 1919, but the number
of cases showed a marked decrease during the last two months.
The month of June saw the spread into England which we have already
described, and the continuation from the German West front back into the
enemy territory.
Rose reports that on the 3d of June, 1918, in Strasbourg the first cases
of influenza were reported in his hospital and that by the 15th of the
month the disease was practically epidemic. Wachter in reporting cases
from Frankfurt a. M. says that the cases of influenza in that city
appeared from the beginning of June, 1918. Schmorl remarks that
influenza became epidemic in Dresden in the beginning of July, 1918.
According to Koepchen, the disease was epidemic in Bonn the 25th of
June.
An editorial comment in the Deutsche medizinische Wochenschrift, July 4,
1918, remarks that the influenza pandemic “which probably has spread
from Spain in the last few days” has appeared in several places in
Germany in the South and the North, and in Berlin. According to the
information received up to that time the disease was of short duration
and without severe complications. The issue of July 11th reports that
the influenza epidemic appears to have already passed its peak in Berlin
and that in Süddeutschland the spread of the epidemic has become very
wide.
The Office International d’Hygiène Publique records that the pandemic
spread throughout Switzerland towards the end of June, 1918, after
having invaded a certain number of European states, coming from various
army fronts. It was at first of mild severity.
Böhm states that the deaths from pneumonia and influenza in Vienna began
to show an increase in the week ending July 30th. In August they
returned to the normal rate. The second wave occurred in Vienna in the
middle of September.
From the information at our disposal we are unable to determine from
what direction the pandemic entered either Switzerland or Austria. The
point of entry into Switzerland is of relatively little importance in
tracing the spread on the continent of Europe. Presumably it entered
from the north or northwest. The disease appeared in Berne in June,
reaching its height in that canton in the middle of July and dying out
in August (Sobernheim and Novkaovie).
Information of the place of entrance into Spain is also rather
indefinite. We are told that Barcelona was one of the cities attacked
early. Barcelona is situated on the Mediterranean near the French border
and is quite directly connected by commerce with Marseilles and other
French ports on the Mediterranean.
In June the disease had also spread to Norway and outside of Europe to
the West Indies, South America, India and China. A short notice in the
Public Health Reports tells us that epidemic influenza with an estimated
number of 1,500 cases began in Christiania, Norway, about June 15th.
Atiles relates that influenza appeared in Porto Rico in June, soon after
the arrival of a ship from Spain. It spread rapidly, and it is estimated
that at one time fully eight per cent. of the entire population had the
disease simultaneously, and that forty per cent. of the population were
affected during the epidemic.
The Health Officer at Bombay made report in July, 1918, on an
influenza-like disease then spreading throughout India. It was stated
that the disease was introduced into Bombay from overseas by a transport
which arrived May 31, 1918; that by June 22d the disease had become
epidemic at Bombay, and that it was present in July, 1918, at Calcutta
and Madras.
The rapid spread from Europe to distant India may be accounted for with
the same mechanism as that by which the disease was spread from America
to France and from France to England, viz. by army transports. The
occurrence of the disease in Porto Rico appears to have been definitely
connected with the arrival of a ship from Spain. A very short notice in
the Public Health Reports tells us that influenza was reported present
at Santos, Brazil, June 16, 1918. We are not informed as to how it
reached that place.
We have discovered no mention of influenza in China in June. It was
reported present in Chungking, China, July 27th. and at that time
one-half of the population was stated to be affected. Dengue was
reported prevalent at Chefoo, China, during the two weeks ended June 15,
1918, and a report from Shanghai of the same date describes the
prevalence of a disease resembling dengue and affecting about 50 per
cent. of the population. The disease in these two latter places may have
been influenza.
The epidemic made its appearance in Korea in September, 1918. Schofield
and Cynn, who report the epidemic, believe that the infection came from
Europe via Siberia. The disease spread from North to South along the
line of the Southern Manchurian Railway.
In August the disease was re-introduced into the United States and by
the end of that month it had acquired a foothold in Boston and vicinity
and rapidly spread to other parts of the country. The pandemic had
crossed the Atlantic in both directions in six months’ time.
In 1918 as in 1889 there are excellent descriptions of the conveyance of
the disease by vessels. The transfer from Spain to Porto Rico has been
mentioned. Escomel says that the outbreak in Rio de Janeiro was ascribed
to infection from a steamship from Spain, the same boat which later
visited Buenos Ayres and started the epidemic in the latter city.
According to a report to the Journal of the American Medical Association
from Mexico the epidemic invaded that country from the North at Laredo
and followed the course from North to South. From a similar source the
same Journal reports that the influenza spread from Buenos Ayres as a
primary focus to Paraguay and there acquired greater virulence.
Hernando reports from the Philippine Islands that influenza was
estimated to have attacked forty per cent. of the total population of
7,000,000 the mortality being about 2.5 per cent. of those attacked. The
epidemic really began in June, although it did not assume great severity
until October. The group of ages that suffered most were those between
ten and twenty-nine years. The disease did not seem to be imported,
since cases were returned before any ships arrived from infected
countries, although after the importation of cases it assumed a more
severe form. The June epidemic seemed to confer a certain degree of
immunity during the second outbreak of the disease in October.
Erlendsson reports that the influenza when it appeared in Iceland in
November, 1918, corresponded in character with that in other portions of
the world. Macklin gives an interesting description of the epidemic as
it occurred in Lapland. The onset in that territory was probably in
November. He found that many individuals recovered in two or three days
and were about their work again feeling perfectly well. If, however,
they contracted pneumonia, about fifty per cent. died.
“The Laplanders had a very thorough if unsympathetic way of dealing with
their cases. The settlements were composed of wooden huts, small but
generally well made and warm. A common type consisted of but one room,
used by the family for all purposes. Better class Laps had better huts,
with two or three rooms. In each settlement one of the single-room huts
had been set apart, and into this each case of sickness as it arose was
unceremoniously pushed; and none were permitted to return to their own
huts until completely recovered. Whilst there they received practically
no attention, and no healthy person ever entered to attend to their
wants. Occasionally a bowl of water or reindeer milk was hastily passed
in at the door, or a huge chunk of reindeer meat thrown in, uncooked and
uncarved.
“We visited every settlement within our reach and entered these huts.
The stench on opening the door met one like a poison blast and the rooms
were nearly always ill lighted and dark. The patients lay littered about
the floor in a crowded mass, fully dressed in clothes and boots (most of
them had no socks), and with no other cover but an occasional greasy
rug. Although the outside air was cold and the ground snow-covered, the
temperature inside, maintained by the combined mass of bodies, was
generally sufficiently high. The patients in these huts included both
sexes and all ages; some, when we entered, sat up and with flushed faces
and dull, uncomprehending eyes watched us listlessly. Others lay
restlessly twisting about, quite incapable of taking any interest or of
answering any questions.”
The epidemic struck Alaska in October, invading first the towns of the
sea coast, being very evidently brought thither by steamer. Travel to
the interior was stopped and so the latter escaped, to a great extent,
the outbreak. At Kodiak and on Cook Inlet, the mortality was extremely
high. Whole villages of esquimaux lost their entire adult population.
Many infants were frozen in their dead mothers’ arms.
_Influenza in China._—We have been able to follow the pandemic quite
consecutively as it has spread around the world, from a first outbreak
in the United States in March, 1918. We repeat that the disease was
presumably present in Europe and elsewhere previous to that time, as it
was in America, but the particular virus which ultimately acquired
sufficient virulence to produce the pandemic may well be that which came
from North America. Did this virus arise from an endemic focus in this
continent, or was it transported to us at a somewhat earlier date from
Asia?
McNalty states that influenza was present in China and in the Japanese
Navy in March of 1918. He gives no reference. Carnwath makes the same
statement and gives as reference the report of Kabeshima and Lee. The
author has not been able to obtain this report.
The Health Officer of Shanghai made the following report for May, 1918:
“Towards the end of the month, reports were received of outbreaks of
‘fever’ which rapidly affected a large proportion of the employees of
various offices, shops, police stations, etc. As a result of clinical
and laboratory observations of cases admitted to the Chinese Isolation
Hospital the disease was recognized as epidemic influenza. The same
disease was reported to have appeared in Peking before reaching
Shanghai, but subsequent reports showed that most of the river ports
were almost simultaneously infected; that is to say the rate of spread
conformed to the rate of conveyance by railways and boats of infected
persons;”
In November of 1918 an editorial note in the China Medical Journal reads
as follows:
“From nearly all parts of China reports are being sent to the newspapers
of the occurrence of a severe epidemic of disease which seems to
manifest itself in various forms. In Wusuch, where the disease is called
‘the five days’ plague’ the symptoms are said to be not unlike those of
cholera, death in some cases ensuing in less than a day. In other cases
it is complicated by severe and often fatal pneumonia. At Anking many
cases have all the symptoms of typhoid fever, but the mortality is great
and sudden. In one house four people died within a few hours of each
other, and in another house eight persons out of eleven died. At Wuhu
and other of the lower Yangtze ports it is said to resemble dengue fever
and the mortality is so great that undertakers are finding it difficult
to meet the demand for coffins. In Shansi, where the victims literally
number thousands, the disease is regarded as influenza. In Peking fully
fifty per cent. of the Chinese have been affected and the mortality has
been heavy. Accurate reports from medical men in these cities would be
very instructive.”
The author has the following personal communication from Doctor Arthur
Stanley of the Health Department of the Shanghai Municipal Council.
“Influenza fever appeared during the recent epidemic in Shanghai towards
the end of May 1918. It swept over the whole country like a tidal wave.
You may take it that it spread like most rapid extant means of transit.
A primary source of origin was not made known.”
It is to be hoped that more definite and concurrent information will be
forthcoming in the case of China. A thorough search of the literature as
reviewed for China and Japan in the China Medical Journal reveals no
description of the disease previous to April or May of 1918.
Nevertheless we must assume that, until contradictory reports are made,
the disease was present in those countries in March as stated by
Carnwath.
AUTUMN SPREAD IN THE UNITED STATES.
By the first of July, 1918, convalescent cases of influenza began to
appear among members of the crews of transports and other vessels
arriving in Boston from European ports. The number of such cases on each
ship was usually not more than four or five, but Woodward records that
in one or two instances between twenty and twenty-five individuals were
sick on incoming vessels. None of these were seriously ill, none were
sent to the hospital, and none died. The disease in this class of
persons did not become severe until late August. Woodward has found on
inquiry among practising physicians that typical cases of influenza were
seen with notable frequency in private practice in the vicinity of
Boston during the month of August, and that they had developed no
serious complications, the only after effect being the marked
prostration.
These mild preliminary cases failed to attract attention; first, because
of their relative scarcity, and second because of their benign
character. Public attention was first directed to the influenza in
Boston by the apparently sudden appearance during the week ending August
28th of about fifty cases at the Naval Station at Commonwealth Pier.
Within the next two weeks over 2,000 cases had occurred in the Naval
forces of the First Naval District. One week later there was a similar
sudden outbreak in the Aviation School and among the Naval Radio men at
the Massachusetts Institute of Technology. The first death in Boston was
reported on September 8th.
The peak of daily incidence in Boston occurred around the first of
October. In the week ending October 5th a total of 1,214 deaths from
influenza and pneumonia was reported, while by the third week of October
this total had fallen to less than 600, and for the week ending November
9th was down to 47. Around November 15th the number of cases rather
suddenly increased and this recurrent wave lasted for about ten days. By
the 25th the rate was back to what it had been around the first of the
same month. On or about December 1st the incidence again rose and
continued increasing daily, to reach its peak in a severe recrudescence
around December 31st.
There are conflicting reports concerning the date of first appearance of
the epidemic at Camp Devens, Massachusetts. Woodward says that a sudden
and very significant increase was reported during the third week in
August in the number of cases of pneumonia occurring in the army
cantonment at Camp Devens, seeming to justify the statement that an
influenza epidemic may have started among the soldiers there even before
it appeared in the naval forces. Soper, on the other hand, as well as
Howard and Love in their official report, place the date of the first
case at Devens as September 7th. Soper remarks: “The Devens epidemic is
supposed to have commenced on September 7, 1918, in D Company, 42d
Infantry. On that date a case of supposed meningitis was sent to the
hospital from this company; on the following day twelve cases were sent
for observation. These proved to be influenza. By the 16th thirty-seven
cases had gone from the same company.” Howard and Love state, “The first
authentic cases of virulent influenza of the great autumn pandemic among
troops in the United States appeared on September 7, 1918, at Camp
Devens, Mass.” These statements by Howard and Love do not eliminate the
possibility of earlier and less virulent unrecognized cases. Wooley, who
was camp epidemiologist, reports that influenza began at Camp Devens on
the 8th of September, 1918. It reached its acme on the 16th, 17th and
18th of the month and then rapidly declined, almost completely vanishing
about the middle of November. He makes no observation as to whether a
mild form of the disease was or was not present in the camp in March and
April preceding.
Influenza entered Massachusetts at Boston. Reeks reports that it entered
Connecticut at New London, the cases coming primarily from the
experimental station and from Fort Trumbull, where vessels from foreign
ports had discharged patients. He believes that the disease was first
introduced by ships arriving in New London from abroad and by men from
the Boston Navy Yard, but numerous foci developed in a short period of
time in various parts of the state. Many of these had appeared by the
middle of September, and the source, according to Winslow and Rogers,
was traced to military establishments, chiefly Camp Devens. In
Wallingford, Willimantic, Hartland, Rockville and Danbury, all of which
towns were attacked early in the epidemic, investigation showed that the
disease developed in each case two or three days after visits of
soldiers from Camp Devens. In Connecticut the epidemic spread, beginning
at New London, chiefly from east to west, reaching its peak in the
Eastern section around October 4th, in the central section October 15th,
and in the Western part of the state around October 24th. Towns which
had been infected early by visitors from military establishments reached
the climax sooner than other towns nearby. In spreading from New London
north and west the large cities of Connecticut were successively
invaded, New Haven and Hartford reaching their crest about ten days
later than New London, while Fairfield County did not reach its acme
until later than New Haven.
In the cities along the New England coast we see then that the disease
reached epidemic proportions early in September. By September 21st it
had become epidemic in a wide area along the Atlantic coast extending
from the Southern part of Maine to Virginia, as well as in a number of
localities scattered over the entire country. By September 28th, areas
adjacent to the centers in which the epidemic had already appeared were
affected, suggesting radial movement from these centers. By that time
the greater part of the New England States, the North Atlantic and
Central States, and some of the Gulf and Pacific Coast States had become
involved. By October 5th the pandemic had apparently reached all parts
of the country with the exception of the more isolated rural districts
and some areas in the Central States and Mountain States. Within an
additional ten days even these areas, with the exception of the very
remote rural districts, had been reached by the epidemic. Within four
weeks the disease had become distributed to all sections of the country,
and within six weeks from its first epidemic prevalence in Boston
practically the entire country had been invaded.
Sydenstricker in a preliminary report remarks on the fact that the
disease reached an epidemic stage in a number of localities in the
central, northern, southern and western sections at about the same time
as it did in the area along the northeastern coast. “The possibility is
suggested, therefore, that sources of infection existed in at least some
of the larger population centers, well distributed through the country,
some time before the disease appeared as a nation-wide epidemic. The
apparent radial spread of the epidemic from certain centers would seem
to strengthen this hypothesis. It may also be noted that there is
evidence, the collection of which has not yet been completed, pointing
to the existence of cases of the disease in various centers, probably
widely distributed, weeks before they were definitely recognized as
influenza. The possibility that these foci themselves had a common focus
is by no means excluded, of course, but there is as yet no conclusive
evidence that would warrant the statement that the starting point of the
epidemic was Boston or any specific locality.”
Dublin, from a study of the statistics of the Metropolitan Life
Insurance Company, finds that the virulence of the influenza, as
indicated by the mortality rate, was greatest along the Atlantic Coast
and became progressively less as it progressed westward. There was one
exception. The mortality was high in San Francisco, higher than in other
western communities. Dublin believes that quite possibly there was a
double infection in San Francisco in the fall of 1918, one coming from
the East and of small caliber, while the other came either by way of the
Panama Canal or perhaps from Asia. The evidence in favor of two ways is
that Dublin finds that the peak of incidence in San Francisco and in
some other places on the Pacific Coast occurred sometime in advance of
the similar peak at points inland from the coast. This is not brought
out in Pearl’s chart, and the latter finds when considering the peak of
deaths that the peak for San Francisco was late. The peak in that city,
in Oakland, California, and in Los Angeles, was reached on the week
ending November 2d. Few cities had as late death peaks. Cleveland and
Pittsburgh reached their peak in the same week, St. Paul, Minnesota in
the week ending November 16th, and St. Louis, Milwaukee and Grand Rapids
not until the week ending December 14th. In the case of Milwaukee and
St. Louis these were the high peak dates but they were second peaks. In
the former the first peak occurred October 26th and in the latter
November 2d. In Grand Rapids the increase in mortality was clearcut by
the middle of October, although the peak was not reached until the week
ending December 14th. These statistics would indicate that San Francisco
was attacked, as evidenced by increase in death reports, relatively
late, and at about the time that would be necessary for the disease to
be carried across the continent.
In an article by Ely, Lloyd, Hitchcock and Nickson it is said that
influenza first appeared in the Puget Sound Navy Yard, near Seattle, on
September 17, 1918, and that it was introduced by a draft of 987 sailors
received from Philadelphia, a number of whom arrived ill, or came down
within a few hours after reaching their destination. As a result,
Seattle and the State of Washington were infected somewhat ahead of the
other West Coast States. According to the record, influenza did not
assume epidemic proportions in the State of Oregon for nearly a month
after this Navy Yard epidemic.