Part 11

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.

With army camps and cantonments situated in nearly every section of the country it is difficult to follow the general direction of spread from camp to camp. During the period of the epidemic, troop movements were in general from West to East toward points of embarkation rather than in the reverse direction. This was in the opposite direction to that taken by the pandemic. Away from the coast there were, however, many movements of troops from camp to camp, in the redistribution of forces. That these troop movements were not discontinued during the epidemic is indicated by the report of Howard and Love: “The virulent type of influenza had spread rapidly from camp to camp, from the Atlantic seaboard to the South and West, due to the continual interchange of personnel from infected to non-infected camps. Such movements of troops at this time were recognized as dangerous and inadvisable, and prompt recommendations were made by the Medical Department that such movements be discontinued or greatly restricted, if compatible with military interests, which, of course, were at the time paramount. The War Department was unable to approve any marked restriction of movement of men from camp to camp at this time. One result of the free inter-communication of military personnel was that practically all military stations in the United States were in the throes of the epidemic at the same time.”

In addition to this means of inter-communication we had the possibility of spread to the various camps by the ordinary course of civilian and commercial travel as in spread to different communities, and also the possibility of importing large amounts of virus at one time on the incoming trains with new draft troops.

Soper gives the following order for camps attacked:

═════════════════╤═════════════════╤═════════════════╤═════════════════ Order. │ Camp. │ Location. │ Date. ─────────────────┼─────────────────┼─────────────────┼───────────────── 1│Devens │Massachusetts │Sept. 12 2│Upton │New York │Sept. 13 3│Lee │Virginia │Sept. 17 4│Dix │New Jersey │Sept. 18 4│Jackson │South Carolina │Sept. 18 │ │ │ 5│Hoboken │New Jersey │Sept. 19 5│Syracuse │New York │Sept. 19 5│Gordon │Georgia │Sept. 19 5│Humphreys │Virginia │Sept. 19 6│Logan │Texas │Sept. 20 │ │ │ 6│Funston │Kansas │Sept. 20 6│Meade │Maryland │Sept. 20 7│Grant │Illinois │Sept. 22 7│Taylor │Kentucky │Sept. 22 8│Sevier │South Carolina │Sept. 23 │ │ │ 8│Lewis │Washington │Sept. 23 8│Newport News │Virginia │Sept. 23 9│Pike │Arkansas │Sept. 24 10│Beauregard │Louisiana │Sept. 25 10│Eustis │Virginia │Sept. 25 │ │ │ 11│Greene │North Carolina │Sept. 26 11│McClellan │Alabama │Sept. 26 12│Kearney │California │Sept. 27 12│Bowie │Texas │Sept. 27 13│Johnston │Florida │Sept. 28 │ │ │ 13│Sheridan │Alabama │Sept. 28 14│Sherman │Ohio │Sept. 29 14│Dodge │Iowa │Sept. 29 14│Shelby │Mississippi │Sept. 29 15│Custer │Michigan │Sept. 30 │ │ │ 16│Travis │Texas │Oct. 1 17│Cody │New Mexico │Oct. 3 18│Forrest │Georgia │Oct. 6 19│MacArthur │Texas │Oct. 7 20│Wadsworth │South Carolina │Oct. 11 │ │ │ 20│Wheeler │Georgia │Oct. 11 20│Greenleaf │Georgia │Oct. 11 ─────────────────┴─────────────────┴─────────────────┴─────────────────

Howard and Love have established definitely that the extension of the virulent influenza from Camp Devens to other camps south and west in September, 1918, can be traced in many instances directly to the interchange of military personnel from infected to non-infected camps. The height of the September outbreak in the United States Army extended over a period of about nine weeks, from Sept. 13th to November 15th, and during this period over 20,000 deaths occurred among troops in the United States alone in excess of the number that would have occurred, if the disease death rate for the corresponding period of the preceding year had prevailed.

It is interesting to note with respect to Camp Humphreys, Virginia, that there were possibly some sporadic cases previous to the autumn outbreak. Brewer in reporting on the epidemic in September and October records the first case as having occurred shortly after July 1st. He makes no mention of there having been any outbreak whatever prior to that date. Between July 1st and September 12th there were only sporadic cases diagnosed as influenza. The autumn outbreak began at Camp Humphreys September 13th and ended October 18th.

RECRUDESCENCES.

We have already seen from the work of Pearl that recrudescences following the original spread in any one locality were the rule rather than the exception in this country. He found that in sixty-five per cent. of the forty cities studied there were two distinct peaks in the mortality curve and in twenty per cent. there were three, while only fifteen per cent. had but one peak. The first peak was as a rule the highest. Although there was no absolute regularity in the time of occurrence of the recrudescences, Pearl established that the high peak cities had the second peaks on an average 7.1 weeks after the first, and the third peak on an average 13.1 weeks after the second. The two-peak cities are divided into two classes, the first comprising about a third of the total number, had the second mortality peak around eight weeks after the first, while the remaining two-thirds had the second peak about thirteen weeks after the first. The cycle in the epidemic wave appears to be nearly a multiple of seven weeks. He suggests that the smaller group of two-peak cities with early second peak may have been cities which at the time were presumably destined to show a third distinct wave and peak of mortality, but in which for some reason not now apparent the third wave did not eventuate. In contradistinction the larger group of two-peak cities with the second peak occurring around thirteen weeks after the first are presumably cities in which the complex of factors determining the form of the mortality curve was such as to lead definitely to a two and only two-peak curve. In three-peak cities the first interval was around seven weeks, the second around thirteen weeks. The two-peak cities with an interval around thirteen were probably not destined, according to Pearl, to have another repetition, but those with an interval of seven were presumably destined to have a second interval, the thirteen-week interval, which for some reason did not occur.

This raises the question of periodicity, a subject which we will discuss at a more appropriate place.

This experience of recrudescences was similar in the American Expeditionary Forces. The first outbreak lasted through April and May and into June. The second came in September and October. The spring epidemic had been characterized by mildness and was known as three-day fever, but in the autumn, complications of the respiratory tract predominated in the symptom complex. By August 18th a severe epidemic had occurred in an artillery camp at La Valdahon in the Jura Mountains, near Bezançon. Early in September a larger epidemic occurred in an artillery camp near Bordeaux. The epidemic in our troops in France, as well as in the French civil and military population, reached its height during October. The Service of Supply was more heavily affected than were the troops situated on the battle front. The morbidity rate appeared to have been almost the same as that in the United States. That it was not quite as high has been shown by Howard and Love. Longcope states that it prevailed particularly among the troops at the base ports where during a part of the epidemic transports laden with infected troops were being landed; in those organizations which contained the largest number of replacement troops; and in organizations being moved on troop trains, where the men were necessarily closely crowded.

The second outbreak subsided during the early part of November. A third occurred in January and February, very much as it had done in the United States. In the interval between the second and third recurrences there was no time at which the entire Expeditionary Forces were free from the disease. The author had occasion to study an outbreak occurring early in December in the 26th Division stationed in rest area at Montigny-le-Roi. In this outbreak the respiratory complications predominated, as in October, and the mortality was comparatively high. We had had occasion to study the same disease at Camp Sevier, South Carolina in September and early October, 1918, and in two different localities in France in December, 1918, and February, 1919, and found that the clinical characteristics were identical on both continents.

The more severe recurrence in England, in October, has been carefully studied. In fact this recurrence was almost universal in all countries. The autumn epidemic has been reported as being at its height in October, 1918, in such widely separated localities as the United States, England, France, Greece, Brazil, India, Japan and Korea.

In Europe at any rate the third wave occurring in the winter of 1919 was quite generally distributed. At about the same time the disease broke out in England, making a third wave in less than a year. Once again the third attack began less suddenly and less violently and resulted in a lower number of fatalities. During February there was reported to have been a great increase in the number of cases in Paris. It had terminated by March 27, 1919. In March the disease broke out anew, this time assuming grave proportions, not only in that city but in several of the Departments.

The second recrudescence has also been reported as being present in Spain.