Description of the epidemic features is not detailed enough to be of assistance. The first group of authors remark that the disease constituted “almost a small epidemic.” The second group say that six out of eight cases in their series of candidly reported patients came from one command. The former report on twenty cases, the latter on eight. The latter remark that although they have dealt with only eight cases in detail, they had a much larger number altogether. Presumably there were a decidedly larger number of patients in both hospitals, but the actual number is not stated. In short, we do not know whether the disease appeared to be more or less epidemic than the apparently similar disease among our troops in the winter of 1917–18.
Both groups of observers have described in some detail the pathology of the cases which were necropsied. The author in attempting to obtain further comparative information has submitted the pathologic descriptions given by the British authors to Dr. E. W. Goodpasture, who has very kindly pointed out the points of similarity and difference between the gross and microscopic findings in these cases of purulent bronchitis, and the same findings in typical influenza. He says that the lung picture, as described, is not the same as that which was typical of the acute influenza observed in the autumn of 1918 and again in the winter of 1920. The characteristic picture in the latter is primarily an extensive involvement of the alveolar structure, while as Abrahams and his associates remarked, the condition in their case is primarily “an affection of the bronchi and bronchioles, and not of the alveoli, though the alveoli may be affected later, if the patient survives long enough.” Goodpasture states that the pathology as described by the British authors is very similar to the lung picture in interstitial bronchopneumonia described by MacCallum for the post-measles and primary bronchopneumonia among our troops in the winter of 1917–18. The streptococcus and the influenza bacillus were dominant organisms in MacCallum’s series. It also resembles the pathologic picture described by Pfeiffer in his original article on one of the late recurrences of the 1889–93 epidemics of influenza.
In summing up, we must admit that it is impossible to reach a definite conclusion, but that both clinically and pathologically the disease described among the British troops in 1916 and 1917 was not typical of influenza as we have known it more recently. The similar conclusion reached by Carnwath, presumably chiefly from epidemiologic considerations, has already been described. We do not deny that this “purulent bronchitis” may have been influenza. On the contrary, it is a part of our hypothesis that influenza under the proper conditions may become epidemic in practically any land. But we do believe that the evidence has not shown that the disease among the British troops in 1916 and 1917 was an etiologic precursor of the great pandemic.
To return to a discussion of influenza in China, we quote from an article by Cadbury in the China Medical Journal: “Unfortunately no health reports are available for the greater part of the Chinese Republic. We have consulted, however, the Health Reports of the Shanghai Municipal Council from 1898 to 1917, and among the total foreign deaths we find that only the following were attributed to influenza: 1899, one death; 1900, one death; 1907, four deaths; 1910, one death. After this no deaths are recorded from this cause up to and including the year 1917.
“In the Hongkong Medical and Sanitary Reports, which give the total deaths registered in the Colony, we have examined the records from 1909 to 1917. During these nine years only two deaths were attributed to influenza, and both occurred in 1909.
“From a personal letter from Dr. Arthur Stanley, Health Officer in Shanghai, dated February 11, 1919, I quote the following:
“‘As to influenza we had an attack beginning at the end of May and lasting through June and again in the latter part of October and lasting through November. The latter was somewhat more severe. The noteworthy features were general absence of catarrhal symptoms, congestive pharynx frequent, as also was a slight erythematous blush on the neck and chest, which made one think at first of scarlet fever. Fatal pneumonia common among the Chinese and Japanese, but among Europeans very little pneumonia.’
“In his report for May, 1918, Dr. Stanley says that the disease was reported to have reached Peking before it came to Shanghai, but subsequent reports showed that most of the river ports were almost simultaneously infected, the rate of spread conforming to the rate of conveyance by railways and boats of infected persons. The mortality was very low.
“Newspaper reports indicate that a third appearance of the disease in Shanghai occurred from the middle of February, 1919, which was still prevalent in April. The symptoms were much more severe.
“For Hongkong I quote from a personal letter from Dr. Hickling, the Principal Medical Officer of Health, dated January 29, 1919: