Part 10

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.