Influenza

by Warren T. Vaughan

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.