Influenza

by Warren T. Vaughan

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.
		France	Civilian Population at Chaumont	MacNeal.
	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.
April		United States	Various points from Norfolk to Louisiana	Public Health Reports.
		Mississippi	Camp Shelby	V. C. Vaughan.
		Georgia	Camp Hancock	Forbes and Snyder.
	30	California	San Quentin Prison	Stanley.
		France		Netter.
				Chauffard.
				Messary.
				Longcope.
	1		Brest (American Expeditionary Forces)	V. C. Vaughan.
			British Expeditionary Forces	Carnwath.
			Allied Western Front	Public Health Reports.
	1		German Western Front	Gins.
May		France	Chaumont	Zinsser.
		Scotland	Glasgow Dunlop,	Carnwath.
		Spain	Madrid	Office International d’Hygiène Publique.
		Greece	Athens	Filtzos.
		Macedonia	French Army	Teissoniere, Beguet and Jolly.
		Egypt	Egyptian Expeditionary Forces	Benjafield.
		Italian Navy		MacNeal.
June		England	Portsmouth	Carnwath.
	15		Birmingham	Public Health Reports.
	1	Switzerland	Zürich	Office International
				d’Hygiène Publique.
	1	Germany	Frankfurt, A. M.	Deutsche. med. Wehnschr.
	3		Strasbourg (Alsace)	Rose.
	25		Bonn	Koepchen.
	At the end of the month		{Berlin {North & South Germany	Deutsche. med. Wehnschr.
	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 Islands		Hernando
July	1	Germany	Dresden	Schmorl.
		Italy		Office 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 States	Boston	Second Spread.
September		Denmark		Frost and Sydenstricker.
	11	Republic of Salvador		Public Health 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 Union		Frost and Sydenstricker.
	16	Senegal	Dakar	Public Health Reports.
	16	Sierra Leone	Freetown	Public Health Reports.
		Korea		Schofield.
		United States	West and South 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, Barranguilla.	Frost and Sydenstricker.
			Cartagena, Peru.	Frost and Sydenstricker.
	9	Cuba	Camagney, Nuevitas	Frost and 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 Guiana		Rose.
		Dutch Guiana	Paramaribo	Frost and Sydenstricker.
	22	Samoa	Apia	Frost and Sydenstricker.
		Arabia	Aden	Frost and Sydenstricker.
		Iceland		Erlendsson.
December		Paraguay	Paraguay, Asuncion	Frost and Sydenstricker.
	19	Dominican Republic	La Plata, Puerto Plata, Santo Domingo	Frost and Sydenstricker.
		Lapland		Macklin.
	8	Society Islands		Frost and Sydenstricker.
	3	Tonga Islands		Frost and Sydenstricker.
		Fiji Islands		Frost and 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.

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.