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    Warren T. Vaughan,1921, Influenza an epidemiological study
    --------------------------------------------------------------------------------------------
    001 GENERAL EPIDEMIOLOGIC CONSIDERATIONS
    047 INFLUENZA EPIDEMICS SINCE 1893
    127 AN INVESTIGATION OF INFLUENZA IN BOSTON (WINTER OF 1920.)
    175 AN INTENSIVE STUDY OF THE SPREAD OF INFLUENZA IN SMALL GROUPS OF
    CLOSELY ASSOCIATED INDIVIDUALS
    199 IMMUNITY
    212 INFLUENZA AND OTHER DISEASES
    224 COMPARISON or INFLUENZA WITH OTHER EPIDEMIC DISEASES
    234 THE PREVENTION AND CONTROL OF INFLUENZA
    245 BIBLIOGRAPHY
    257-260 APPENDIX
    ------------------------------------------------------------------------------------------------------------------------------------
    -001 GENERAL EPIDEMIOLOGIC CONSIDERATIONS
    002 Historical
    013 Clinical and epidemiologic identification
    014 General characteristics of early epidemic outbreaks
    019 Symptoms in former epidemics
    020 Manner of spread
    023 Human intercourse
    026 Crowd gatherings
    027 Mass attack
    030 Healthy carriers and convalescents
    031 General manner of spread in individual localities
    031 Primary type of epidemic
    033 Secondary type of epidemic
    036 Mortality curves
    037 Duration of explosive outbreak
    041 Morbidity curves in 1920 recurrences
    042 Spread in countries and continents
    042 Spread in primary waves
    044 Spread in recurrences
    -047 INFLUENZA EPIDEMICS SINCE 1893
    047 Occurrence since 1893
    047 Period from 1893-1918
    049 Increase in 1900-1901
    051 Period from 1901-1915
    055 Influenza in 1915-1916
    058 Influenza between 1916 and 1918
    059 The pandemic of 1918
    065 Date of first increased prevalence in various localities
    080 Influenza in China
    081 Autumn spread in the United States
    087 Recrudescences
    089 Recurrences in the winter of 1919-1920
    090 The winter of 1920
    095 Incubationperiod
    096 Predisposing causes
    097 Periodicity
    108 Virulence enhancement
    113 Meteorologic conditions
    114 Secondary invaders
    116 Origin of the 1918 pandemic
    -127 AN INVESTIGATION OF INFLUENZA IN BOSTON (WINTER OF 1920.)
    134 Diagnostic standards for the 1918 epidemic
    134 Standards for 1920
    137 Morbidity
    143 Relation of sex to morbidity
    145 Relation of sex to severity
    145 Morbidity by age
    150 Relationship of occupation to morbidity
    155 Effect of race stock
    156 Mortality
    165 Mortality by sex
    167 Relationship to age
    170 Relationship of occupation
    170 Density of population
    173 Race stock and mortality
    -175 AN INTENSIVE STUDY OF THE SPREAD OF INFLUENZA IN SMALL GROUPS
    OF CLOSELY ASSOCIATED INDIVIDUALS
    179 Effect of overcrowding
    187 Domestic cleanliness
    189 Economic status
    191 Distribution of the disease through the household
    194 The first case in the family
    197 Intimacy of family contact
    198 Recurrent cases
    -199 IMMUNITY
    -212 INFLUENZA AND OTHER DISEASES
    212 Influenza and tuberculosis
    220 Other infectious diseases
    222 Encephalitis lethargica
    -224 COMPARISON or INFLUENZA WITH OTHER EPIDEMIC DISEASES
    224 Epizootics
    228 Asiatic cholera
    228 Epidemic meningitis
    229 Plague
    231 Measles
    -234 THE PREVENTION AND CONTROL OF INFLUENZA
    236 Anticipatory or preventive measures
    237 Organizationof health services
    239 Palliative measures in the presence of an epidemic
    241 Problems for the future.Constructive research
    245 Bibliography



    Vaughan,1920
    page 137, MORBIDITY.
    There has been great actual variation in the morbidity from influenza
    in the various epidemics and even in different localities during single
    epidemics. Previous to 1889 there were no reliable statistics for the
    disease incidence, and subsequent to that date the records, for the
    reasons previously mentioned, have still been not entirely adequate.
    In the history of influenza morbidity,as in that of its mortality, we must
    content ourselves for information prior to the nineteenth century with
    the very general estimates made by contemporary historians.During
    the last century the statistics have been more numerous and more
    nearly correct.-----------------------------------------------------------------------------------------------------------------------

    As far back as the first recognized pandemic, 1510,
    the extremely high morbidity has been a recognized characteristic.
    Thomas Short in speaking of this pandemic says, "The disease
    attacked at once and raged all over Europe, not missing a family
    and scarce a person." ---------------------------------------------------------------------------1510-------------------------

    Pasquierin 1557 spoke of the disease as
    common to all individuals, and Valleriola describes the widespread
    distribution of the epidemic throughout the whole of France during
    that year.It spared neither sex, age, nor rank, neither children nor
    aged,rich nor poor.The mortality, however,was low,"children only,
    dying." Again,Thomas Short remarks, "This disease seized most
    countries very suddenly when it entered, catching thousands the
    same moment." ------------------------------------------------------------------------------------1557? or still 1510--------------

    Of the second pandemic, 1580,Short says,
    "Though all had it,few died in these countries except such as were
    let blood of,or had unsound viscera." ----------------------------------------------------------------------1580-----------------

    Thomas Sydenham remarks that in the epidemic of 1675 no one
    escaped, whatever might be his age or temperament,and the disease
    ran throughout whole families at once.--------------------------------------------------------------------1675----------------

    Molineux recorded concerning 1693,"All conditions of persons were
    attacked,those residing in the country as well as those in the city;
    those who lived in the fresh air and those who kept to their rooms;
    those who were very strong and hardy were taken in the same manner
    as the weak and spoiled; men, women and children, persons of all
    ranks and stations in life,the youngest as well as the oldest."---------------------------------1693------------

    Schrook tells us that in Augsburg in 1712 not a house was spared
    by the disease.
    According to Waldschmidt in Kiel, ten and more persons were
    frequently taken ill in one house,and Slevogt says that the disease
    was fearful because so many persons contracted it at the same time.
    The disease was, however, not dangerous, for Slevogt continues:
    "Fear soon vanished when it was seen that although it had spread
    all over the city,it left the sick with equal rapidity."-----------------------------------------------1712-----------------------

    It is estimated that in the epidemic of 1729-1730, 60000 people
    developed the disease in Rome, 50000 in Mayence, and 14000 in
    Turin. In London "barely one per cent,escaped." In Lausanne
    one-half of the population,then estimated at 4000,was stricken.
    In Vienna over 60000 persons were affected. In the monasteries
    of Paris so many of the inmates were suffering from the disease
    that no services could be held. -----------------------------------------------------------------1729f---------------------

    Huxham is quoted in Thomson's
    "Annals" as declaring concerning the epidemic of 1732-33:
    "Not a house was free from it,the beggar's hut and the nobleman's
    palace were alike subject to its attack,scarce a person escaping
    either in town or country;old and young, strong and infirm,shared
    the same fate."------------------------------------------------------------------------------------1732f------------------------

    Finkler writes as follows concerning the epidemic of 1758: "On
    Oct. 24th, Whytt continues,the pestilence began to abate.
    He is not sure whether this was due to a change in the weather,
    or because the disease had already attacked most people,
    although the latter seems more plausible to him, particularly as
    he says that 'in Edinburgh and its vicinity not one out of six or
    seven escaped, 'and in other localities it is said to have been even
    worse. In the north of Scotland also, the epidemic was greatly
    disseminated from the middle of October to the end of November.
    A young physician wrote to Robert Whytt: 'It was the most
    universal epidemic I ever saw,and I am persuaded that more
    people were seized with it than escaped.'
    This same physician reported that 'it was not at all mortal here.'"--------------------1758---------------

    In the epidemic of 1762,we learn from Razoux,de Brest, Saillant,
    Ehrmann, that the morbidity was great while the mortality was low.----------------1762---------------

    According to Grimm,nine-tenths of the inhabitants of Eisenach
    contracted the disease in 1767.------------------------------------------------------------------1767---------------------

    Daniel Rainy,of Dublin,in describing the invasion of an institution
    in 1775-76,tells us that from among 367 persons varying in age
    from 12 to 90 years, 200 were taken sick.
    Thomas Glass says:
    "There sickened in Exeter Hospital all the 173 inmates, 162 had
    coughs. Two or three days after the hospital was invaded the
    cityworkhouse as attacked;of the 200 paupers housed there only
    very few escaped the disease." -------------------------------------------------------------1775f---------------------

    Gilibert described an extraordinary morbidity in Russia in 1780-81.------------1780f-------------------

    Metzger says that in 1782 the Russian catarrh was so universal
    during the month of March that in many houses all the inhabitants
    were attacked.During this period, "in St.Petersburg, 30000, and
    in Konigsberg, 1000 persons fell ill each day;"in Rome two-thirds
    of the inhabitants were attacked; in Munich, three-fourths; and in
    Vienna the severity of the epidemic compelled the authorities to
    close the theaters for eight days.----------------------------------------------------------1782--------------------------

    The epidemics of 1788-89, 1799-1800 and of 1802-1803 were----------------------1788f , 1799f, 1802f-------------
    characterized by a relatively lower morbidity than that of 1830-32,
    in which the morbidity was again enormous.--------------------------------------------1830-2---------------------------

    Likewise in 1833, the morbidity was very great. In Prague "scarcely
    a house was spared by the plague." In Petrograd, 10000 persons
    were attacked; in Berlin at least 50000.These are the figures of
    Hufeland.The Gazette M&iicale records the morbidity as being
    four-fifths of the total number of inhabitants of Paris. --------------------------------1833----------------------------

    In 1836, according
    to Gluge, 40000 persons suffered from the disease in Berlin alone. ------------------1836-----------------------

    In London, in the 1847 epidemic, it has been calculated
    that at least 250000 individuals took sick, and in Paris, according to
    Marc d'Espine,between one-fourth and one-half of the population
    developed the disease,and in Geneva not less than one-third.. --------------------1847-----------------------------

    Leichtenstern informs us that in 1890 the early reports were made
    by clinical men and were mere presumptions. They were almost
    universally higher than the later statistical findings.
    The early estimates for the morbidity in several German cities were
    from 40-50 percent. On the other hand,one of the highest statistical
    reports recorded by Leichtenstern was for Strasbourg in which 36.5
    per cent, of the individuals became sick.
    The average morbidity reported by him ran between 20 and 30 percent.
    The difference is accounted for in part by the fact that some of the
    very mild cases were not recorded in the statistics,and in part by
    the tendency in giving estimates,to exaggerate.Auerbach has collected
    the statistics of 200 families distributed throughout the city of Cologne.
    He found that 149 of these families (75 per cent.) were attacked.
    In these, 235 were ill 59 men, 95 women,and 81 children.The larger
    number of women was explained as due to the illness of the female
    servants.He estimates each family as consisting on an average of
    six individuals,and concludes that 20 percent, were taken with the
    disease.
    Following the 1889 epidemic,Abbott concluded,on a basis of
    questionnaries sent out to various individuals and institutions in the
    State of Massachusetts,that 39 percent, of the entire population had
    been attacked,in all about 850000 persons. -----------------------------------------------------1889f---------------------------

    Moody and Capps,in
    December, 1915, and January, 1916, made a survey of the personnel
    and inmates of four institutions in Chicago, the Michael Reese Hospital,
    the Illinois Training School for Nurses, the Old Men's Home,and
    St. Luke's Hospital Nurses Training School, making a total of 677
    persons surveyed, of whom 144 developed influenza, making a
    percentage morbidity of 21. They remarked that there were many
    others with colds who remained on duty and were not included in the
    table and were not diagnosed as influenza. ---------------------------------------------------1915f---------------------------

    We have already described the relatively low morbidity and mortality
    in the early spring epidemic in the United States.
    According to Soper, the total number affected in March, 1918, at Camp
    Forrest and the Reserve Officers Training Camp in the Oglethorpe
    Camps was estimated at 2900. The total strength at that time was
    28586. The percentage morbidity then was probably a little over
    10 percent.
    Dunlop, in describing the May, 1918, epidemic in Glasgow, says that
    it was more limited in extent,as well as milder,than the later epidemic. ------------------1918 1st wave-------------

    It has been estimated that in the autumn epidemic in the United
    States Army Camps one out of every four men had influenza,and one
    out of every twenty-four men encamped in this country had pneumonia.
    During the four autumn months of 1918, 338343 cases of influenza
    were reported to the Surgeon General's Office;there were 61691 cases
    of pneumonia.
    Woolley reports that among the soldiers at Camp Devens,Mass.
    30 percent, of the population was affected.
    At Camp Humphreys,16 percent, of the entire personnel developed
    the disease. The camp had an average strength of 26600 individuals.
    52 percent, of the entire number of cases occurred during the peak
    week,which ended October 4th.The outbreak began September 13th
    and ended October 18th. Hirsch and McKinney report that an
    epidemic of unusual virulence swept with great rapidity through
    several organizations in Camp Grant between September 21, 1918,
    and October 18, 1918. During this time 9037 patients were admitted
    to the Base Hospital, representing about one-fourth of the strength
    of the camp,and of these, 26 percent,developed pneumonia.
    About 11 percent, of the total admissions or 43 percent, of the total
    cases of pneumonia died.

    ...


    ================================================== ====
    page 156
    MORTALITY.
    According to Marchese, in 1387 at Forli in Italy, not a person
    escaped the disease,but only a few died.
    Gassar says that during the same epidemic in Germany the patients
    suffered four,or at most five, days with the most disagreeable
    catarrhal symptoms and delirium,but recovered,and only very few
    were removed by death.-------------------------------------------------------------------------------1387---------------------

    Pasquier remarks concerning an epidemic in 1411 that an infinitude
    of individuals were attacked but that none died.-----------------------------------------------1411-------------------

    Concerning the epidemic of 1414 in France,Lobineau relates that
    the disease was fatal only for the aged.
    Mezeray also speaks of the high mortality of the old in this epidemic.----------1414-----------------

    Regarding the pandemic of 1510,Thomas Short remarks that none
    died except some children.
    Mezeray,on the other hand, says that the disease had claimed
    many victims. ----------------------------------------------------------------------------------------------1510----------------

    Pasquier and Valleriola both write of the epidemic of 1557,
    in France, as being distinctly mild in character.
    Children only who could not freely cough out the phlegm died.
    Coyttar speaks of the absence of death except in tuberculous
    patients. --------------------------------------------------------------------------------------------------------------1557-------------------

    In the pandemic of 1580 individual observers report enormous
    death rates.Thus, according to Schenkius,the disease killed 9000
    persons in Rome,while Madrid, Barcelona and other Spanish cities
    were said to have been nearly depopulated by the disease.
    This high mortality was, however,even at that time attributed
    by some physicians to the injudicious employment
    of venesection.
    Throughout the more recent history of pandemic influenza opinion
    seems to have been nearly unanimous that bloodletting has had
    very bad results in the outcome of influenza cases.
    Remarks to this effect have been made by the contempories
    of nearly every epidemic since 1580.-----------------------------------------------------------------------------1580--------------

    According to Rayger and others during the epidemic of 1675,
    nobody died of the disease itself with the exception of debilitated
    persons, although it spared neither the weak nor the strong. ----------------------------------1675-------------------

    Concerning the epidemic of 1688,Thomas Short writes for England
    that though not one of fifteen escaped it, yet not one of a thousand
    that had it died.------------------------------------------------------------------------------------------------1688---------------

    In 1712, Slevogt writes that in Germany "Fear soon vanished when
    it was seen that although it had spread all over the city,
    it left the sick with equal rapidity."---------------------------------------------------------------------------1712--------------------

    Finkler remarks, concerning 1729-30, that, "The great mortality
    which attended the epidemic in England and Italy seems
    somewhat remarkable.
    Thus Hahn states that in London in the month of September
    1000 persons died each week,and in Mayence 40 persons
    daily. Most likely, however,other diseases which were present at the
    same time added their quota to the mortality, especially as the
    disease in other places,for example in Germany,ran a benign course." ----------------------1729f-------------------

    Perkins, Huxham,Pelargus,Carl and others, concerning the
    epidemic of 1732-33, all testify that the disease was of very low fatality.--------------1732f--------------

    In 1742 the epidemic was evidenced by an enormous morbidity but
    the disease was not dangerous as a general rule although Huxham
    occasionally speaks of the virulent character of the disease in England,
    and Cohansen says that in January, 1743, over 8000 persons
    died from influenza in Rome and 5000 in Mayence.-----------------------------------------------1742f------------------

    We have the testimony of Robert Whytt,for 1758,and that of ----------------------------1758----------------------
    Razoux and Saillant and Ehrman for 1762,as to the low mortality of------------------1762-----------------------
    the epidemic for those years.

    According to Heberden the same was true for 1775,------------------------------------1775--------------------
    while Webster tells us for 1780 that the disease was not dangerous
    but its effects were seen the following year in the increased number
    of cases of phthisis. --------------------------------------------------------------------------------1780------------

    Finkler remarks concerning the epidemic of 1802,
    "The mortality in this epidemic was small, only the abuse
    of venesection brought many to the grave.
    Thus,so many farmers are said to have died in Russia
    from it that venesection was forbidden by an imperial
    ukase.
    Jonas says that many patients were bled either on the advice
    of a simple village barber or by their own wish, and most of them died.
    In Prussia also bleeding was declared detrimental by the Government." ------------------1802---------------

    He continues regarding 1836-37, that, "In London there died,
    during the week ending January 24, 1837,a total of 871 persons,and
    among these deaths there were 295 from disease of the respiratory
    organs; during the week ending January 31st, out of a total of 860
    deaths there were 309 from diseases of the respiratory organs." ----------------------------1836f-------------------

    Watson, in describing the epidemic of 1847,discusses the mortality
    "The absolute mortality has been enormous; yet the relative
    mortality has been small.
    You will hear people comparing the ravages of
    the influenza with those of the cholera,and inferring that the latter is
    the less dangerous complaint of the two;but this is plainly a great
    misapprehension.
    Less dangerous to the community at large (in this
    country at least) it certainly has been; but infinitely more dangerous to
    the individuals attacked by it.
    More persons have died of the influenza in the present year than died
    of the cholera when it raged in 1832;
    but then a vastly greater number have been affected with the one
    disease than with the other.
    I suppose that nearly one-half of those who were seized with the
    cholera perished;while but a very small fraction, indeed, not
    more probably than two percent, of those who suffered influenza
    have sunk under it." ---------------------------------------------------------------------------------------1847-------------------------

    Leichtenstern remarks on the very low mortality of 1889-90.
    In Munich 0.6% died;in Rostock 0.8%; in Leipzig 0.5%
    in 15 Swiss cities 0.1%; in Karlsruhe 0.075%;
    in Mecklenburg-Schwerin 1.2%.
    This does not, however, include the numerous deaths from
    complications,as from pneumonia, and does not
    express the true mortality.
    Newsholme gives the following table for mortality from influenza,
    bronchitis and pneumonia,in England and Wales during the epidemic
    years and the years immediately preceding them.
    The figures express annual death rate per million of population.
    The highest rate was reached in 1891.
    The table does not include deaths registered as from
    other diseases,but due directly or indirectly to influenza.
    Respiratory diseases in general show a greatly increased
    death rate in years in which influenza is epidemic.
    Such is also true to some extent with
    diseases of the nervous and the circulatory systems.


    ---------------------------------------------------------------------------------------------------------1889ff------------------------------


    ================================================== ================
    Vaughan, 202

    We have previously shown that the relatively low morbidity among
    the older age groups in 1918 is not satisfactorily explained by an
    immunity lasting over from the epidemic of 1889-93.
    If such were the case the change in mortality rate in large groups of individuals
    would occur at the age of 30.

    ================================================== =======


    Vaughan page 199ff IMMUNITY.

    Opinions of all observers who have studied in detail the question
    of immunity in influenza are remarkedly in accord.
    The conclusions reached by Parkes in 1876 are valid today,
    and form as excellent an abstract of our present knowledge as any
    produced since his time.
    "There is some discrepancy of evidence, but,on the whole,
    it seems clear that, while persons seldom have a second attack in the same
    epidemic (though even this may occur),an attack in one does not
    protect against a subsequent epidemic.
    Indeed,it has been supposed rather to render the body more liable."
    In 1890, Abbott wrote: "There is but little if any evidence in
    support of the protective power of one attack to confer immunity against
    a second;and hence adults are not exempt,as they usually are in
    epidemics of scarlet fever or other exanthemata;so that the proportion
    of adults to children attacked in an epidemic is necessarily greater
    than that which is observed in epidemics of other infectious diseases."
    Parsons made somewhat similar observations: "One attack of
    influenza does not seem to be protective against another;the disease in
    this respect resembling diphtheria, erysipelas,and cholera rather than
    smallpox, measles,or whooping cough.
    The duration of the epidemic in a locality is so short that it is difficult
    to distinguish between second attacks properly so-called,
    and relapses,which are frequent enough.
    A case is recorded in the 'British Medical Journal' of February 15, 1890,
    in which a patient who had suffered from influenza in France in
    December,1889, had another attack in England in January, 1890.
    It was noticed in 1837 that many persons suffered from influenza
    who had had the disease during the previous epidemic in 1834.
    The shortness of the interval between these two epidemics,as compared
    with that between 1848 and 1889, seems to show that the periodical
    return of the disease in an epidemic form does not depend upon the
    accumulation in the interval of susceptible individuals unprotected
    against the disease by aprevious attack.
    If one attack afforded protection against another a large proportion
    of the population in 1837 must have been protected, yet an epidemic
    occurred,and on the other hand for many years before 1889 a large
    majority of the population must have been unprotected by a previous
    attack, yet the epidemic did not recur.
    "The persons now living who passed through the disease in 1847
    are of course comparatively few, but such persons have not been
    exempt from the present epidemic.
    "I should be inclined to attribute the short duration of the influenza
    epidemic in a locality to the establishment of a tolerance for the
    specific poison among the persons exposed to it,similar to the tolerance
    for dust possessed by workmen in rag factories,as mentioned,but
    which is soon lost on their ceasing to be exposed to it,rather than
    to a true immunity being established.
    "Relapses in influenza are of frequent occurrence; they occurred
    in 9.2%, of the cases at the Morningside Asylum, Edinburgh,
    and in some cases indeed a second relapse has been recorded.
    The time at which the relapse occurs is usually from a week to a
    fortnight after the primary attack,and it can often be distinctly traced
    to an exposure to cold,or return to work before complete recovery.
    The symptoms of the relapse are similar to those of the primary attack,
    except that they are commonly more severe."
    In his report of 1893, Parsons goes into the subject of recurrent
    attacks in individuals in greater detail. He quotes several communications
    received from various physicians and health officers.
    These opinions differ,some believing that the disease predisposes to
    another attack; others, that there is no effect on the incidence in
    recurring epidemics;and still others believing that there is a small
    amount of acquired immunity.
    The communications are not based upon statistical evidence.
    He does find, however, an opportunity
    for statistical study in the industrial schools at Swinton near
    Manchester: "These schools were severely affected in March, 1890,
    171 out of 589 children having suffered,or 29% In the first epidemic
    of 1891 they were again affected,but to a less extent, only 35
    cases occurring. At that time there were in the schools 449 children
    who had been there at the time of the former epidemic. Of these
    150 had had influenza in 1890 and 4 of them had it again,or 2.6%
    299 had escaped influenza in 1890 and 17 of these had it now,or 5.7%
    Thus,so far as these figures go,an attack of influenza confers a
    degree of protection which after the lapse of a year diminishes
    by one half the liability to contract the disease."
    Leichtenstern, like Parsons, recognizes the importance of
    distinguishing between relapses and recurrent cases.
    Relapses in influenza are not common. They usually occur after the patient
    is up, and about when he is ready to leave the house.
    These are not recurrent cases, but in the epidemics in the years
    following 1889 there were plenty of well substantiated cases
    of recurrent typical influenza in the
    same individual and some times even in entire families.
    During the 1889 epidemic, as during the 1918 epidemic
    it has been suggested by various observers that the apparent
    immunity among the very old was due to immunity developed
    as the result of previous epidemics, such as that of 1837,1847 and 1857.
    Leichtenstern has collected the statistics from five different
    hospitals in which 8%,32%,35%,24%,and 24% of individuals attacked
    in 1891-92 had already had the disease in 1889.
    Allbutt in 1905 remarked that whereas he had previously believed
    that immunity to influenza usually persists as long as six months,
    many cases had recently been brought to his notice where such an
    interval seemed improbable, where the succeeding attack was probably
    not a relapse but a new infection.He has seen two attacks apparently
    separate occurring in the same individual within two months.
    In the same year Moore wrote that influenza shows a decided tendency
    to relapse,a feature to which the indirect fatality of the disease is in
    great measure due. "So far from establishing immunity,an attack
    of this malady seems to render an individual more liable to contract
    the disease upon any future exposure to its contagion."
    Again West,in the same year wrote,"From our present experience
    we must conclude that influenza is infectious in a very high degree
    indeed, and that the protection afforded by an attack is imperfect,
    or of very short duration.Indeed, one attack -seems actually to
    predispose,after a time to another, or, to put it differently,that the
    positive phase of protection is followed by a negative phase, in which
    the individual seems rather more than less liable to succumb to infection
    if exposed to it. It seems more likely that an individual may
    never have influenza at all than that, having had it once, he should
    never have it again. Some, indeed,seem to offer so little resistance
    that they develop it regularly once or twice a year."
    We have previously shown that the relatively low morbidity among
    the older age groups in 1918 is not satisfactorily explained by an
    immunity lasting over from the e pidemicof 1889-93. If such were the
    case the change in mortalityrate in large groups of individuals would
    occur at the age of 30.
    During the autumn of 1918 many observations were made, particularly
    in the armies, of light incidence in those groups or communities
    that had had the disease in mild form in the spring of the same year.
    Parsons quotes many similar observations for the period 1890-1893.
    V. C.Vaughan relates that at Camp Shelby, Mississippi,"there
    was in April a division of troops numbering about 26000.
    An epidemic of mild influenza struck this camp in April, 1918,and within
    ten days there were about 2000 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 20000 recruits.In
    October, 1918, the virulent form of influenza struck 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 2000 who had the disease in April,but the 24000
    who apparently were not affected escaped the fall epidemic.
    It appears from this that the mild form of influenza of April gave a
    marked degree of immunity against the virulent form in October.
    There is another observation which points the same way.Looking
    over the statistics of the fall epidemic in cities in the United States we
    find that certain cities had a low death rate,while others had a
    relatively highrate. Among those cities which had a low death rate we will
    mention Atlanta,Ga.;Kansas City,Mo.; Detroit, Mich.,and Columbus, Ohio.
    Going to the spring records of these cities we find that in
    all of them in March and April of 1918 there was an unusually high
    death rate from pneumonia and undoubtedly in these cities at that
    time there was a relatively mild epidemic of influenza.
    In this way I am inclined to account for the relatively low death rate in these cities
    in the fall of 1918. I make no claim that this and other instances of a
    similar kind prove that the mild and virulent forms of influenza are
    manifestations of the same disease, but I do hold that the evidence
    points that way."
    Lemierre and Raymond report the following observation in favor
    of the development of a certain degree of immunity in the French
    troops in April, 1918. After an intervening period of quiescence
    there was a manifest recrudescence at the end of August.
    Many military formations were attacked during both periods.This was
    true especially in three groups of an artillery regiment under their
    observation.In the first of these groups there were three cases in
    April, while 114 men were attacked in August.In the third group
    there were 100 cases in April and only 3 in August.In the second
    group there were 20 cases in April and 59 in August.Their report
    does not state the total number of individuals in each of the three
    groups. Jolt rain and Baufle discuss the flaring up of the epidemic in
    October, and relate that a troop of soldiers from Indo-Chinan early all had
    the disease lightly in the spring, but when the disease appeared again
    it spared this troop completely,while troops and civilians around
    developed it in a severe form.Gibbon writes:
    "During the last three waves of the epidemic I had
    to deal with the sick of 2000 troops,and during this time we treated
    in hospital over 400 cases.No cases admitted in June, July or August
    were re-admitted in October, November,or December,and no cases
    admitted in either of these two periods were re-admitted in February
    this year.
    Unfortunately I am unable to trace the cases into March
    as the troops were changed."
    Dopter reports recurrent epidemics of influenza in a French Army
    Division in 1918.The division,of which he was surgeon,was one of
    the first to contract la grippe at the time of its first appearance in the
    zone of the armies at the end of April,1918.
    At this time nearly the entire body of infantry troops was attacked.
    The disease was mild, and without complications.
    The regiment of artillery escaped nearly entirely.
    This epidemic subsided very rapidly,and by the end of May
    it had entirely disappeared.Early in August a group of heavy artillery
    was attached to the division, bringing influenza with it.Then a
    few cases appeared in the regiment of light artillery which had hitherto
    escaped. By the end of August all three groups of this regiment had
    been attacked.
    In this second epidemic the men who had come
    through the first unattacked were very severely
    ill in the second.With rare exceptions those sick in the
    first did not contract it again.
    Dopter notes that in the battery the most severely affected
    in August,of which the effectives were reduced almost to none, only
    those men were considered well enough for duty who had had
    influenza in the first period.They escaped the second in spite of the close
    contact with their comrades.
    The infantry regiments,which were in
    close association with the artillery,remained unaffected.
    Finally,toward the middle of September new troops were attached
    to the division,in view of an imminent attack by the enemy.These
    troops, coming from neighboring and distant formations were suffering
    at the time from grip,and continued to have the disease in the new
    sector.Again,those attacked in May passed without damage through
    this new epidemic.Among them there were only rare isolated mild
    cases.The recurrences made only 1.6%, of the total incidence.
    Opie and his associates found that at Camp Funston after the first
    wave of influenza in March and April, 1918, the succeeding waves
    usually affected only new recruits,who had not been in camp during
    previous waves.
    In Calcutta influenza appeared as an epidemic in July, 1918,and
    in November, 1918. During the first quarter of 1919,at Calcutta as
    elsewhere, many cases were still recurring.Malone investigated the
    incidence of the disease in three institutions of Calcutta : He found that
    in 'the Gourepore Jute Mills where the population was practically
    stationary,those individuals who were attacked in July, 1918, passed
    through two later epidemics, in December, 1918, and February, 1919,
    without contracting the disease a second time,in spite of intimate
    contact with infected persons. The same was true according to
    Malone in the Alipore Central Jail and the Presidency Jail in Calcutta.
    He believes that his evidence strongly suggests an immunity lasting
    for at least nine months.
    Dunlop found that Glasgow had a mild epidemic in the month of
    May, 1918,in which the death rate rose from 14.1 to 20.1.There is
    no record of any similar outbreak in Edinburgh. In the July epidemic
    the Glasgow death rate rose from 11.7 to 15.9, while the Edinburgh
    death rate went from 11.3 to 18.0,a higher increase. In the October-
    November epidemic the Glasgow rate rose from 11.0 to 38.4, while the
    Edinburgh rate went from 10.8 to 46.2. In the February-March
    epidemic theGlasgow rate rose from 14.9 to 48.3,and the Edinburgh
    rate from 18.9 to 52. 1 In the July and October epidemics Edinburgh
    showed a greater increase in death rate, while in February,1919,
    the increase in the two cities was the same.
    However,in this case probably other factors play a part.
    Also, we must remember that
    here we are dealing with death rates,not with incidence rates.
    The Inspector General of Health,in Spain, reported in January,
    1918, that those cities which had the disease in May, 1918,suffered
    lightly in the autumn of that year, while others of the large cities
    which had been spared in the first invasion suffered most in the second.
    Maillard and Brune report an epidemic of influenza in an epileptic
    colony.There were 32 deaths among the 63 cases. None of the
    inmates of the hospital who had influenza during the June epidemic
    contracted it anew during the October wave.
    Ovazza records that although a number of persons contracted
    the influenza anew on its return in the fall after having had it in the
    spring, yet the return cases were strikingly mild,and always free from
    complications.
    Barthe'lemy describes the successive waves of epidemic influenza
    at Bizerte.He found that the "doctors and nurses who had been
    through the first epidemic did not develop influenza in the second one
    a few months later,even though they came in the closest contact with
    the patients.
    Hamilton and Leonard have studied two successive outbreaks due
    to lapses in a rigid quarantine in an institution of 180 girls between
    12 and 18 years of age. The girls were distributed through six cottages.
    In the first epidemic November, 1918, 76 girls contracted the disease,
    at which time it was entirely limited to the occupants of cottages 2, 3,
    and 4. The second outbreak occurred in January, 1919,when 82 took
    ill. Only five of these were located in cottages 2 and 4, the remainder
    being in 1,5 and 6. No cases occurred in cottage 3 during the second spread.
    Both epidemics lasted a little under two weeks.
    Those who had suffered in the first spread appeared to be immune to
    the second. There were no recurrences.The second epidemic was
    much milder in character.Twelve percent, of the total remained
    well throughout both epidemics.
    Dr.Niven,in his study of 1021 households previously described,
    found that 105 families suffered in both the summer and autumn 1918
    epidemics."They comprised a population of 565 persons,of whom
    205 suffered in summer and 360 escaped. In the autumn epidemic
    82(=40%) of the presumably 'protected' persons
    succumbed again,whereas only 120 (=33%) of the 'unprotected' suffered.
    Of the former, however, only one died,while five of the latter terminated fatally.
    These are interesting figures.If
    they are borne out by subsequent inquiry, they are somewhat difficult
    of explanation.
    The persistent susceptibility to the primary disease
    and yet comparative immunity from the fatal sequel, would seem to
    suggest a dual infection, against one element of which the body is able
    to produce protection,while it is unable to do so against the other."
    Frost made a canvass of 33776 individuals in Baltimore between
    November 20th and December llth,1918. The same population was
    again covered in January, 1919, to determine the extent of the recru-
    descence reported in December. Among 32600 people,724 cases of
    influenza had occurred in the interval since the first survey.Of this
    number only 26 or 3.6%, were definitely cases of second attack
    in the same individual.
    Even in these cases the diagnosis is necessarily uncertain.
    Frost says that considering that 23%, of the population had had
    influenza prior to December llth, the proportion of
    second attacks should have been much greater
    if no immunity had been acquired.
    A second canvas in San Francisco gave generally
    corresponding results.
    Our own experience was quite similar.We have divided the whole
    period from March, 1918 to March, 1920,into two portions separated
    at August 1,1919.In the first portion we have knowledge of but four
    individuals suffering from what the records would indicate to be two
    genuine attacks of influenza.Similarly,five individuals appeared to
    have had two attacks within the second interval.These are to be
    contrasted with a total incidence in the fall and winter of 1918-1919
    of 1971 cases,and in the winter of 1919-20,of 965 cases.Among the
    total nine individuals the intervals between attacks varied from 26
    days to five months.All except one had an interval of one month or over.
    In two cases there was an interval of one month,in one an
    interval of two months,in two an interval of three months,in one of
    four months,and in one of five months. None of the four individuals
    who had two attacks in the first group of months had a subsequent
    attack in the second. On the contrary, two of the five suffering two
    attacks in the second group of months had one previous attack in the
    first.The second attack, following the first by a relatively short
    interval tended to be milder than the first.In five out of the entire
    nine the second attack was milder,in two it was of the same degree
    of severity,and in only two was it more severe than the first.
    The order of severity in the two individuals having three attacks each
    was, in the first, severe, mild, severe;in the second, severe, average,
    average. Zinsser makes the following remark: "The writer himself believes
    that he had three attacks during the last epidemic.The first and
    second were mild ones and the third complicated and therefore severe;
    and innumerable others with whom he has spoken have had similar
    experiences." From a consideration of these reports by divers authorities it
    is reasonable to conclude that for a period of a few months at least,one
    attack of influenza protects against a second. As is to be expected,
    this relative immunity is not of constant duration in all individuals.
    If there were no lessened susceptibility following an attack we would be
    faced with the phenomenon of individuals succumbing time and again
    to rapidly successsive attacks of the disease.
    Such a circumstance is very rare.
    It is difficult to determine how long even on an average this relative
    protection or insusceptibility lasts. Evidence is fairly uniform in
    indicating a protection of at least three months. Usually it is longer.
    There seems to be some basis for the supposition that a group of
    individuals exposed to an attack of influenza displays within the
    succeeding three months, or slightly longer,a relative general group immunity.
    If the group be considered as a whole those even who did not develop
    the disease previously appear to have become less susceptible.
    Whether we can ascribe this to the individual as a unit,or whether we
    must explain it by some assumption with the community as a unit,
    is uncertain. Is it because the exposed individuals in the group who
    did not contract the disease have individually received some of the
    virus into their systems and developed a certain immunity, or is it a
    much more complex phenomenon depending on greater relative dis-
    persion of susceptibles and other communal factors ?
    We may place the minumum period of "immunity"at from three to
    five months, rarely less.
    There is additional evidence by which we may
    delimit fairly closely the other extreme,that time at which individuals
    considered as a group no longer manifest increased resistance to the
    disease. The author found that 19.17%, of his population contracted
    influenza in 1918,and 9.55%, contracted the disease in 1920.
    240 individuals, or 2.4%, of the entire population developed the disease in both epidemics.
    Out of 1971 individuals having the disease in the 1918 spread, 240, or 12.1%
    recurred in 1920. This is to be compared with the total 1920 incidence of 9.55%.
    More correctly we should separate the
    1920 cases into 2 groups, those who had and who had not had
    influenza previously. The former group, 240 individuals, constitute
    as just stated, 12.1%, of all who had had the disease previously.
    The second group, 715 individuals, constitute 8.9%, of the
    8034 who had not had the disease in 1918-19.
    From these results we must conclude that a previous attack con-
    tracted on an average of from 10 to 17 months before, conferred no pro-
    tection whatever against a second attack.On the contrary, the attack
    rate was slightly higher in this group than in those who had not previously
    had the disease.
    Yet another evidence of the insignificant part played by any immu-
    nityin the occurrence of influenza in individuals in 1920 is indicated by
    our series of 319 infants living in 1920 but who had not been born dur-
    ing the 1918 spread and who were presumably not immune to the
    disease.We have not investigated whether the mothers had had the
    disease in 1918.From among these 319 infants, 30=10%.,
    developed the disease in 1920. This is practically the same percentage
    as for the population at large.
    These findings also correspond with our previously recorded con-
    clusion made after studying the disease incidence with three increasing
    degrees of exposure, sleep,room and family (page 198).
    TABLE IX.
    Comparison of the severity of the first and second attacks in individuals contracting
    influenzain 1918-19 and again in 1920.
    Severity.
    1918,and that 22.6%, were attacked in 1920.
    Of those who had the disease in 1918-19, 21.2%, had a repeated attack in 1920,
    while of those who had not had a previous attack, 23.1%, were attacked in 1920.
    A similar study among 2472 men at Camp Grant showed that 15.8%
    had had influenza in 1918-19, and 11.7% in 1920.
    Of those with previous influenza history 15.6%, had a repeated
    attack, while of the remainder without previous history of influenza
    10.9%, were attacked in 1920. They conclude that no marked
    immunity to influenza exists 12 to 15 months after a previous attack,
    but that the results do not show that some degree of immunity may
    not obtain at an earlier period.
    It is interesting while considering the subject of immunity to pay
    particular attention to those who did not develop the disease as well as
    to those who did.
    In our series 70%, of all individuals escaped the disease in both epidemics.
    With some variation this figure will hold for all communities.
    Or, again, among those who had the disease
    in 1920, 75%, had not had it in the preceding waves.
    Hall states that in Copenhagen at the Bispebjaerg Hospital, among
    the 500 patients with influenza in the four weeks early in 1920,
    91.8%, had not had the influenza during the 1918-19 epidemic.
    H. F.Vaughan found in a review of 2500 cases occurring in Detroit
    in January, 1920, that 84%, had never had the influenza before.
    The true significance of these figures cannot be recognized,because
    we are not informed as to the percent, of these populations attacked
    in 1918-19.
    We observed such a universal distribution of influenza during the
    epidemic period that it is frequently assumed that all individuals are
    exposed to the disease, that the virus must enter the body of all or
    nearly all,and that it is due chiefly to a relative natural immunity that
    some do not fall victims. Is this the actual state,or is it true that the
    distribution of the virus is limited to about one-third of the population
    and that practically all of those who are actually exposed develop the
    disease ? These are the two extremes; more probably the actual
    state is somewhere between.
    This question cannot be definitely answered, and yet it is one of
    extreme importance, particularly with regard to prevention and
    combat of the disease. How universally is the influenza virus distributed
    during pandemics ? What proportion of the population is actually
    exposed by invasion with the virus ? What proportion of actually
    exposed individuals develops the disease? We will refer to this again
    when comparing influenza with other infectious diseases, but it is of
    particular interest now to review our individuals who were exposed by
    sleeping with cases of influenza. 55% of all individuals
    sleeping in the same bed with cases of influenza in 1918 did not
    contract clinical influenza. 70% of all individuals sleeping
    with influenza cases in 1920 did not contract the disease in
    recognizable form.69% of all individuals in 1920 who had
    not had the disease previously and who slept with cases did not
    develop evidence of the disease.
    It is a bit difficult to conceive of a degree of exposure much closer than
    that of sleeping in the same bed with a sick individual. And yet it is
    equally conceivable that many individuals sleeping sleeping in the same bed
    with a patient were not penetrated by the virus of influenza. This
    does not aid us in answering our question. We do not know whether
    the more important factor is that of a natural immunity or that of
    absence of actual invasion by the virus.


    ... experiments with volunteers....

    ================================================== =========
    several problems:
    1.) how to explain the unusual age-distribution of cases in 1918, if not with immunity ?
    it could come from 1889, but age-dependent, short-lived in children before puberty
    2.) immunity was reported in 2009 , by showing antibodies, aged 60 or more,
    having had exposure to a strain from the 40s or 50s
    3.) mice immunized with the 1918 virus showed longlived immunity
    4.) CFR in 1920 was way down, although the age-distribution could still be seen,
    that vanished almost completely in subsequent years
    How to explain this, if not by exposure to the virus in 1918,1919 ?
    From the sequences we have no signs, that the virus changed
    substantially from 1918 to 1920.
    And those regions who were spared in 1918 had it worse in 1920
    5.) in Mexico City, Bojoca,Lima we had only incomplete protection of the elderly in 1918
    6.) isolated populations had no protection of the elderly (Mamelund)
    7.) isolated populations were shown to have more severe attacks
    even in 1968, Tristan da Cunha. American Indians, Aleutes,Maori,Aborigenes

    8.) we now know that there are several forms of immunity and several different
    influenza viruses

    ================================================== =======
    http://www.ncbi.nlm.nih.gov/pubmed/23863506 , 14 months, mice
    http://www.ncbi.nlm.nih.gov/pubmed/23637797 , 15 months, mallards
    http://www.ncbi.nlm.nih.gov/pubmed/22884662 , 24 months, boosted, humans
    http://www.ncbi.nlm.nih.gov/pubmed/22130546 , 16 months, mice
    http://www.ncbi.nlm.nih.gov/pubmed/19596414 , chickens, 32 months
    http://www.ncbi.nlm.nih.gov/pubmed/23812238, humans, 45 years (?)
    http://en.wikipedia.org/wiki/Antibod...d_cytotoxicity
    http://www.ncbi.nlm.nih.gov/pubmed/23785769 , humans, 45y , B-cell
    http://www.ncbi.nlm.nih.gov/pubmed/23785204 , NA
    ------------------------------------------
    http://www.nature.com/nature/journal...ture12202.html
    http://www.nejm.org/doi/full/10.1056/NEJMra1002842
    Preclinical studies have shown that these candidate vaccines stimulate broadly
    cross-reacting antibody responses when administered either alone or in combination
    with adjuvants or carrier proteins, and several of these vaccines are now undergoing
    clinical testing. 61-64

    61. Steel J, Lowen AC, Wang T, et al. An influenza virus vaccine based on the con-
    served hemagglutinin stalk domain. MBio 2010;1(1):e00018.
    62. Schotsaert M, De Filette M, Fiers W, Saelens X. Universal M2 ectodomain-based influenza
    A vaccines: preclinical and clini-cal developments. Expert Rev Vaccines 2009;8:499-508.
    63. ClinicalTrials.gov. Comparative safety and immunogenicity of 1.0 µg intramuscular (i.m.) and 2.0 µg
    subcutaneous (s.c.) dosing with VAX102 (M2e-flagellin) universal influenza vaccine in healthy adults. 2009
    http://www.clinicaltrials.gov/ct2/sh...iversal&rank=2
    64. Idem. Safety study of recombinant M2e influenza-A vaccine in healthy adults (FLU-A). 2008.
    http://www.clinicaltrials.gov/ct2/sh...erm=M2e&rank=2
    --------------------------------------------------------------------------------------------
    The development of influenza A virus (IAV) vaccines capable of inducing
    cytotoxic CD8 T cell responses could potentially provide superior, long-term
    protection against multiple, heterologous strains of IAV

    Granzyme B-high, lung-resident T-cell populations persist for at least 4 months
    and can control a lethal influenza challenge without harmful cytokine responses,
    weight loss, or lung injury.






    ================================================== =======
    Comby found that in Paris only the new-born were noticeably insusceptible
    to influenza,that children up to 15 years were attacked at 40%,and adults at 60%
    Danchez believed that in families in which all the adults became ill,the
    little children usually escaped.
    Finkler states that in the schools at Bordeaux the older children
    were first and most frequently attacked.
    Of the 248 male and female teachers in 41 schools, 153 (61.7%) developed the disease.
    Children up to five or six years of age at any rate seem to have been
    very little affected,while older children were no less susceptible than adults.
    Among 47,000 cases of influenza treated by physicians in Bavaria in 1889,
    the various ages were as follows:
    1,1.5%,2-5,5.4%,6-10,6.6%,11-15,7.2%,16-20,11.4%,21-30,22.2%,
    31-40,19.3%,41-50,12.6%,51-60,7.7%,61-70,3.6%,71-80,2.0%,>80,0.5%
    Leubuscher recorded that in Jena the proportion of cases in the
    individual age classes did not correspond with the figures reported
    from other localities.
    Children, and especially very young children,
    suffered relatively less than adults.
    The following statistics of the 1889-90 incidence of influenza
    among school children in Cologne were collected by Lent:
    age,%affected in Cologne,% in suburbs
    13-14,33.8,42.9%
    11-12,31.9,37.9
    10,30.5,37.1
    9,25.9,31.4
    8,28.0,28.2
    7,22.3,26.3

    Theages showing highest mortalityin the autumn of 1918appear
    to have beenessentiallythe same as those whichpredominated thirty
    years ago.
    Thereappearsto benothingin theagedistribution that
    could beexplained byanimmunity persistingover from theepidemic
    of 1889-93.

    ================================================== ==============
    Attached Files
    I'm interested in expert panflu damage estimates
    my current links: http://bit.ly/hFI7H ILI-charts: http://bit.ly/CcRgT

  • #2
    Re: old flu surveys

    120 pages, .pdf in German, in Deutsch


    https://archive.org/details/influenzaeineges00kusn

    "Influenza. Eine geschichtliche und klinische studie"
    Dr. A. Ch. Kusnezow, (Charkov)
    Wien,1890

    good history

    page 39, flu more severe in Burjates than Russians

    Im J. 1873 (vom Januar bis März) ergriff die Influenzaepidemie ganz Nord-Amerika, wo
    ihr im J. 1872 eine starke Influenza unter den Pferden vorausgieng:

    Im Winter des J. 1874—75 verbreitete sich die Influenza ungemein rasch über die westliche und
    östliche Halbkugel:in Nord-Amerika, im südwestlichen Deutschland, in Österreich. Frankreich,
    Nord-Italien und Schweden.


    Alle folgenden Influenzaepidemien verliefen so harmlos und beschränkten sich bloss auf vereinzelte
    Punkte, dass ihrer in der Literatur kaum Erwähnung geschieht. So macht Henderson^) über die
    Influenza Mittheilungen,die im J. 1874 einen epidemischen Charakter in Helensburg annahm, wo
    sie alljährlich im Herbst auftritt. Im J. 1877 war ihre Neigung zu Recidiven sehr bemerkenswert;
    selbe stellten sich
    gewöhnlich 4—10 Tage nach der ersten Genesung ein, so dass sich infolge dessen die Krankheit
    mitunter durch 6—7 Wochen hinzog. Im Februar 1878 trat, nach Eade, plötzlich eine starke Influenza-
    epidemie in East-Anglia auf, wo sie den grösseren Theil der Bevölkerung ergriff.2)
    2) Eade, P. „Influenza in East-Anglia". Lancet. March. 1878. 16. Ref. in
    Virchow und Hirsch. Jahresbericht. 1878.— „Influenza in East-AngUa". Lancet. 1890. Nr. 5.
    [East England, 1878]


    [deadly flu in cats, 5 obductions showed catarrh from nose to bronchies]
    interessant ist folgendes Beispiel : Eine Katze mit deutlich ausgeprägten Symptomen der Influenza kam
    zu einer Familie, die 5 ganz gesunde Katzen hatte. Die kranke Katze befand sich im Verkehr mit den
    gesunden, frass mit ihnen aus einem Gefäss, wobei in die Nahrung nicht selten ihr eigenes Secret
    aus Mund und Nase floss; selbstverständlich wurde diese Flüssigkeit auch von den gesunden
    Thieren mitgefressen. Nach 6 Tagen crepirte diese neu dazuge- kommene kranke Katze.
    Die Obduction derselben zeigte einen intensiven Katarrh der Schleimhäute der Respirationswege
    von der Nase angefangen bis in die feinsten Bronchien. Nach 2 Tagen erkrankten 5 andere Katzen,
    von denen 4 zugrunde giengen ;ihre Obduction zeigte das nämliche pathologisch-anatomische Bild.

    -------edit---------------------

    yearly influenza in Helensburg (Helensburgh,Scotland ?) before 1877
    usually in fall, often recurrent in 1877 with prolonged disease for 6-7 weeks

    Henderson, Fr. „On the influenza recently prevalent. Glasgow med.
    Journ. Oct.p. 502. Ref.in Virchow und Hirsch's Jahresbericht 1877.
    So macht Henderson^) über die Influenza Mittheilungen,die im J.1874 einen
    epidemischen Charakter in Helensburg annahm, wo sie alljährlich im Herbst
    auftritt. Im J. 1877 war ihre Neigung zu Recidiven sehr bemerkenswert;
    selbestellten sich gewöhnlich 4—10 Tage nach der ersten Genesung ein,
    so dass sich infolge dessen die Krankheit mitunter durch 6—7 Wochen hinzog.
    http://en.wikipedia.org/wiki/Helensburgh
    I'm interested in expert panflu damage estimates
    my current links: http://bit.ly/hFI7H ILI-charts: http://bit.ly/CcRgT

    Comment


    • #3
      Re: old flu surveys

      4.) CFR in 1920 was way down, although the age-distribution could still be seen,
      that vanished almost completely in subsequent years
      How to explain this, if not by exposure to the virus in 1918,1919 ?
      From the sequences we have no signs, that the virus changed
      substantially from 1918 to 1920.
      Since we are learning that genetics may play a big part in severe outcomes, an alternative explanation is that the susceptible were already killed in the early waves.
      Last edited by Emily; March 6, 2014, 06:25 PM. Reason: Typo fix.
      Never forget Excalibur.
      “‘i love myself.’ the quietest. simplest. most powerful. revolution ever.” ---- nayyirah waheed
      Avatar: Franz Marc, Liegender Hund im Schnee 1911 (My posts are not intended as advice or professional assessments of any kind.)

      Comment


      • #4
        Re: old flu surveys

        ahh, flu can't kill so many suspectables.
        It depends on contacts, whether the suspectables were exposed in their
        city, environment, family. ~10%-20% of people were infected per wave

        and how then explain the age-distribution
        I'm interested in expert panflu damage estimates
        my current links: http://bit.ly/hFI7H ILI-charts: http://bit.ly/CcRgT

        Comment


        • #5
          Re: old flu surveys

          Originally posted by gsgs View Post
          ahh, flu can't kill so many suspectables.
          It depends on contacts, whether the suspectables were exposed in their
          city, environment, family. ~10%-20% of people were infected per wave

          and how then explain the age-distribution
          I'm not denying the importance of immunity, but in 1918-20, I think flu infection was generally more dangerous than today, and I thought that the 1918 virus was thought to be more transmissible than seasonal flu, so was the infection rate per wave even higher than 10-20%?.

          http://www.air-worldwide.com/Publica...-Flu-Pandemic/
          Modeling a Modern-Day Spanish Flu Pandemic

          February 21, 2013
          ...
          Compared to other flu viruses, the virus that caused the 1918 pandemic was highly transmissible (as measured by the basic reproduction number, R0, the number of new infections generated by an infected person entering into a population with no immunity to the disease). For seasonal flu, the average R0 value is around 1.30, but the median R0 for the 1918 pandemic was much higher, ranging from 1.80 to 2.48. In some regions, the R0 of the pandemic pathogen even soared to 4.50.
          Then there is another factor thought to contribute to the age-distribution:

          While the cause of this unique CFR profile has not been fully resolved, two contributing factors have been identified. First, the 1918 virus’s high virulence triggered a “cytokine storm” overreaction of the immune system, which often leads to pneumonia and death in certain victims by suppressing the body’s antiviral responses and promoting increased inflammation. Young, healthy adults are more likely than other age groups to suffer a cytokine storm because their immune systems are robust and, therefore, more prone to overreaction. Second, bacterial co-infections such as pneumococcal pneumonia and tuberculosis were much more widespread in 1918, especially among young adults. Because the interaction of influenza virus infection and bacterial infection can cause severe illness, widespread bacterial co-infections led to increased mortality.

          Also the sharp drop in CFR might have been due to host behavior ceasing to favor the spread of lethal virus mutations (Paul Ewald's hypothesis):

          http://www.flutrackers.com/forum/sho...d.php?t=219607
          If a host is infected with a mild form of the pathogen, then the host can continue functioning, is more likely to be in contact with other potential hosts, and the pathogen is more likely to spread and replicate. Therefore, natural selection will favor strains that only mildly affect the host. However, there was a potential reversal of conditions during World War I. If a soldier on the war front was infected with a mild form of influenza, he stayed on the war front, only contaminating others around him. However, soldiers who were infected with a particularly virulent form of influenza were removed from the trenches and transport d in crowded troop trucks to crowded clinics or hospitals, giving the virus ample opportunities to infect many more hosts. Thus, the evolution of a virulent strain of influenza was favored, and this newly emerged pathogenic virus devastated the world (as reported in Gladwell, 1997).
          Never forget Excalibur.
          “‘i love myself.’ the quietest. simplest. most powerful. revolution ever.” ---- nayyirah waheed
          Avatar: Franz Marc, Liegender Hund im Schnee 1911 (My posts are not intended as advice or professional assessments of any kind.)

          Comment


          • #6
            Re: old flu surveys

            Vaughan's Boston survey, post#1 above:
            The author found that 19.17%, of his population contracted
            influenza in 1918,and 9.55%, contracted the disease in 1920.
            -----------------------------------------------------
            if it were genetical, then you'd expect death-clusters
            among realtives. They were not found, I even vaguely remember
            a study on twins.
            -------------------------------------------
            some places that were spared in 1918 got it badly in 1920.
            Hawaii,Japan,Columbia (?)
            -------------------------------------------------
            most still died from bacterial pneumonia, but not elderly.
            Compare with 1889, flu waves in previous seasons.
            This was unusual. We saw similar protection in 1957,1968,1977,2009
            --------------------------------------------
            1918-2nd-wave flu was very successful despite being virulent.
            1920-flu- had lower infection rates
            Immunity was clearly demonstrated 1918-wave1 --> 1918 wave2
            ---------------------------------------------
            if some few were just suspectable to death, some of them should
            have survived and then had severe disease again in 1920.
            I'm not aware of this (severe in 1918-->severe in 1920)
            -------------------------------------------------
            it was equally severe in groups of different ethnics
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            Comment


            • #7
              Re: old flu surveys

              afair it was the u-melbourne survey that argued there was no flu in England
              ~1860-1889 and thus no H1 that could have induced immunity in those
              aged 29-~58 in 1918.
              They list only very few deaths in England during that period caused
              by influenza and pneumonia.
              But death-numbers from all causes were elevated in England in early 1875,
              as elsewhere in Europe and America . In winter 1874/75 there was the most
              notable flu wave in that period, some even called it a pandemic.
              Attached Files
              I'm interested in expert panflu damage estimates
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              • #8
                Re: old flu surveys

                if it were genetical, then you'd expect death-clusters
                among realtives. They were not found, I even vaguely remember
                a study on twins.
                I found a family death cluster, even have photos of their graves:

                http://www.flutrackers.com/forum/sho...d.php?t=178323

                It was stunning. We'd spent a lot of time looking for evidence of pandemic at that old cemetery. We certainly saw time-clustering of deaths, usually the very young - 1910 is one bad year I remember. But 1918-1920 looked like a better time or at least no worse than any other time-clustering of deaths during the days before modern medicines and sanitation - until we found that family's graves.

                They were Sami.
                https://www.duo.uio.no/bitstream/han...17308/4823.pdf
                There's another paper in the cemetery thread.
                Never forget Excalibur.
                “‘i love myself.’ the quietest. simplest. most powerful. revolution ever.” ---- nayyirah waheed
                Avatar: Franz Marc, Liegender Hund im Schnee 1911 (My posts are not intended as advice or professional assessments of any kind.)

                Comment


                • #9
                  Re: old flu surveys

                  Rippberger, 1892 in German

                  https://archive.org/details/dieinfluenzaihre00ripp

                  geschichtlichen Darstellungen Schweich's (1836) und Gluge's (1837)

                  Adams,1809.
                  Biermer,1865.
                  Paris. 1873.
                  Bub, Ludwig, Würzburg 1868.
                  BurseriuS, Joh Bapt., Opera medica. Lipsiae 1826.
                  Copland, 1840.
                  Cullen, 1789.
                  Leipzig 1786.
                  Fodere, Paris 1822.
                  Frank, Joseph, 1826.
                  Fuster,Montpellier 1861.
                  Gluge,Gottlieb, Die Influenza oder Grippe.Minden 1837.
                  Graut, W., (London 1775,1782).Leipzig 1784.
                  Haeser,Jena 1876.
                  De influentia epidemica.Diss Jenae 1834.
                  Hagen, Erlangen 1858.
                  Hancock, Thomas, 1833.
                  Hirsch, Aug., 1881.
                  Knappich, Franz, Histor. Skizze über d. Influenza. diss München 1854.
                  Kratz, Walther. Leipzig 1890.
                  Kusnezow, Herrmann, Wien 1890.
                  Lessing, Berlin 1838.
                  Macdonald, 1890
                  Most, Gg.Frdr., 1820
                  Leipzig 1834.
                  RohatzSCh, 1839
                  Sailiant, Paris 1780.
                  Schnurrer,Frdr., Stuttgart 1813.
                  Tübingen 1823.
                  Schweich,Heinr., Die Influenza.Berlin 1836.
                  Seitz,Frz., 186
                  Smith,J. New-York 1829.
                  Spaniol,Jaicob, diss Würzburg 1884.
                  Sprengel, Halle 1803.
                  Thompson, London 1852.
                  Thompson,E.Symes, London 1890.
                  Villalba, Madrid 1803.
                  Velden,Rieh. (1874—75) Diss. Strassburg 1875.
                  Walter, Wien 1890.
                  Webster, Hartfort 1799.
                  Wittwer, Phil. Nürnberg 1782.
                  Zeviani, Modena 1804.
                  Zuelzer W., Leipzig 1886.

                  > An wirklich guten Darstellungen der Geschichte der Influenza fehlt es.
                  > Schweich bis 1834, reichlicher Literaturangabe.
                  > Influenza Europaea« von Most.
                  > Besser als alle : Gluge

                  first clear influenza in 1387

                  Die Epidemie [in 1387] ist, wie schon erwähnt, die erste, von der wir
                  mit Sicherheit sagen können, dass es sich wirklich um Influenza handelte.

                  >90% infected, only some elderly died, children more spared

                  1403

                  1411 >unzweifelhaft influenza
                  >100K in Paris , old people dying

                  seit dem Jahre 1850 bis 1889 kaum ein Jahr verflossen,
                  in dem nicht die Influenza bald in grösserer, bald in geringerer Ausdehnung
                  aufgetreten war.


                  December 1850 in Westindien
                  1865 von Influenza frei
                  Influenza-Epidemie im März 1866 in Frankreichs^) und im Mai
                  dieses Jahres in England (-->age >52 in 1918)
                  in 1869 nicht epidemisch
                  1872 frei von Influenza,
                  Februar 1878 in East-Anglia,
                  I'm interested in expert panflu damage estimates
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                  Comment


                  • #10
                    Re: old flu surveys

                    Davidson,1892, geographical pathology
                    https://archive.org/details/geographicalpath01davi

                    Influenza.—Although we are quite justified in believing that epidemics of influenza
                    have frequently occurred in the past, of which no record remains, the medical history
                    of the nineteenth century goes far to prove that few regions are less exposed to these
                    visitations than the Indian peninsula.

                    That the disease is both
                    rare and mild in India, may be inferred from the statement of Mac-
                    kinnon
                    :
                    "In no Indian authors that I know of is influenza described ; and, with some knowledge
                    of army returns, I venture to say they will equally show that epidemic influenza
                    is here unknown."- This, as we have seen, is not strictly accurate.

                    The following is the monthly percentage of deaths from respiratory diseases in the native army of India founded upon the returns of 1864-73 as given by Bryden
                    :—Jan.Feb.Mar.Apr.May.Jun.Jul.Aug.Sep.Oct.Nov. Dec.
                    21.8,12.8,10.8,07-9,06.0,02.8,02.0,02.7,02.2,03.7,10-3,16-4
                    09.7,12.6,10.3,08.7,08.7,07.4,03.0,06.0.06.8,09.4, 06.5,11.0 in Bombay,1855

                    [gs: astonishing how deaths from respiratory diseases (mainly bronchitis,pneumonia)
                    were (are ?) still so much seasonal even at places close to the equator]
                    I'm interested in expert panflu damage estimates
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                    Comment


                    • #11
                      Ruhemann , Leipzig,1891, ueber die Pandemie 1889/90 mit 50 Seiten Historie
                      http://wahrheit-kompakt.net/files/Im...inde00ruhe.pdf

                      001,I. Rückblick auf" frühere Influenzapandemieen
                      050,1 II. Der Gang der Epidemie von 1889/90
                      069,III. Ueber die ätiologischen Verhältnisse der Influenza
                      080,IV. Symptomatologie und Verlauf der Influenza
                      106,V. Complicationen seitens der Brustorgane
                      122,VI. Complicationen und Nachkrankheiten seitens des Nervensystems
                      135,VII. Psychosen und Influenza
                      144,VIII. Influenza und Augenerkrankungen
                      156,IX. Influenza und Ohrenerkrankungen
                      163,X. Einfluss der Influenza auf Erkrankungen der weiblichen Sexualorgane
                      168,XI. Complicatorische Erscheinungen seitens der Haut und
                      des uropoetischen Systems
                      171XII. Wirkung der Influenza auf andere Krankheiten
                      177,XIII. Behandlung der Influenza
                      183,XIV. Zusammenfassende Bemerkungen

                      -----------------------------------------------------------------------------------------------------------------------

                      ---------- Gluge,1837, in German. historical influenza
                      http://reader.digitale-sammlungen.de...030_00005.html

                      Chinese origin ?, p43 , almost yearly occurrance
                      Transactions of the medical society of Calcutta, Vol.VI,p.358


                      --------------------------------------------------------------------------------------------------------------------
                      Journal - American Medical Association"
                      at http://archive.org
                      halfyearly editions of >500 pages each , e.g.
                      1887,1890 , since 1883, I assume

                      -------------------------------------------------------------------------------------------------------------------
                      also BMJ british medical journal, e.g. 1890: 197MB,pdf at archive.org A careful examination
                      of the records tegarding the noted epidemics of influenza in
                      London during the last forty-five years, by Sir Arthur Mitchell,M.D., and
                      Dr. Buchan (see Brilish MedicalJournal, April 12, 1890), p.859 --> small note there only
                      paper maybe published in Journal of the Scottish Meteorological Society, 1893]

                      [was there anything that could have provided the supposed immunity of the elderly in 1918 ?]

                      ----------------------------------------------------------------------------------------------------
                      I'm interested in expert panflu damage estimates
                      my current links: http://bit.ly/hFI7H ILI-charts: http://bit.ly/CcRgT

                      Comment


                      • #12

                        I just found that in
                        ‘A Most Protean Disease’: Aligning Medical
                        Knowledge of Modern Influenza, 1890–1914 [2012]
                        MICHAEL BRESALIER
                        http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3483746/

                        quotes Parsons on page 494 (page 14 into the .pdf) :

                        > One striking discrepancy was the relative absence of ‘catarrh’ in 1890. [58]

                        [---------------edit------------ this may just refer to catarrhal symptoms
                        in Russian-flu-cases, rather than parallel catarrhial fever (common colds, flu-H1)]

                        [58] Parsons, op. cit. (note 30), 54.
                        [30] H.F. Parsons, Local Government Board, Report on the Influenza Epidemic
                        of 1889–1890 (London: HMSO,1891), 120.
                        [ "catarrhal fever" was most prevalent in Britain and Europe in 1850-1890
                        but it rarely was deadly.
                        19th century textbooks categorised influenza as an epidemic 'catarrhal fever ] HMSO:
                        http://en.wikipedia.org/w/index.php?...on&redirect=no



                        I see this as evidence that the common catarrhal fever in 1850-1889 was indeed
                        mild influenza, possibly of type H1, with few deaths.
                        It was maybe "killed" in 1890 by the new emerging "Russian" pandemic flu,
                        probably of type H3 or H2, widespread and more deadly.
                        We typically saw this replacement of old flu strains in other pandemics.
                        Presumably caused by some short-term, subtype-unspecific immunity
                        (~3months) that disrupts the chain of transmission of earlier strains.

                        By that theory the H1 circulating before 1890 had provided longterm,
                        subtype-specific immunity to the elderly for 1918.
                        Without that lucky immunity we would probably have seen ~3 times
                        as many deaths and a "normal" age-distribution, killing mainly the elderly.


                        it would be interesting to see, if this [relative, they still had common colds]
                        absence of catarrhal fever in 1890
                        and following years is confirmed elsewhere.
                        Any ideas, where to search ?

                        ============================================ 1890 flu : relapses on the eighth day.
                        shivering and lumbar pain.
                        In some persons it is the stomach and digestive organs
                        which are attacked, leading to violent vomiting or colic and diarrhoja
                        In other cases catarrhal symptoms of any kind are absent or very slight,

                        M. Brouardel stated, during the discussion at the Academy of Medicine, that
                        grippe is always characterised by the precursory symptoms 'of headache,
                        nausea, prostration, symptoms which are not present in pulmonary catarrh,
                        which has been described as grippe.

                        In nearly all the muscular pain is most marked, and in
                        many the severe headache is a prominent symptom.
                        In very few is there much na'jal catarrh or conjunctival symptoms.
                        In a few cases the abdominal symptoms are the leading feature

                        ]makes me wonder whether Parsons absence of catarrh in 1890
                        refers to catarrhal symptoms within Russian flu or independent
                        catarrhal diseases]

                        North of London as well as the North-West, very generally, but
                        at present the cases are of a very mild type : catarrhal fever, with
                        great lassitude,frontal headache, pains in the limbs, and a general chilliness for
                        two or three days, such as is felt in mild cases of malaria.
                        Some cases are attended by a rose-coloured rash, and the temperature
                        rises to 102°. In a private case the temperature was 104°,
                        --------------------------------------
                        Aberdeen has not yet [1890/01/11] been visited by Russian influenza.
                        So far as I know an abnormally large number of catarrhs,
                        and what popularly is termed "influenza" prevail, but no well-
                        defined case of the dreaded stranger has yet been seen.
                        --------------------------------------
                        I'm interested in expert panflu damage estimates
                        my current links: http://bit.ly/hFI7H ILI-charts: http://bit.ly/CcRgT

                        Comment


                        • #13
                          http://catalog.hathitrust.org/Record/009704180
                          Papers on the epidemic of influenza from 1889 to 1892: relation between influenza and catarrhal fever. The epidemic as seen in Philadelphia from 1889 to 1891. The treatment of influenza and its sequelae. The heart as influenced by the epidemic: with other notes. Notes on the outbreak of influenza and its treatment during the fall and early winter of 1891. By Roland G. Curtin and Edward W. Watson.

                          http://babel.hathitrust.org/cgi/pt?i...view=1up;seq=5


                          http://mssa.library.yale.edu/obituar...24/1889-90.pdf
                          OBITUARY RECORD OF GRADUATES OF YALE UNIVERSITY
                          Deceased during the Academical Tear ending in June, 189O.
                          [PRESENTED AT THE MEETING OF THE ALUMNI, JUNE 24th, 1890.]
                          ...
                          He died in Hartford, January 10, 1890, in his 80th year, of
                          heart-failure, following an attack of influenza, which had run
                          into catarrhal fever

                          Below are obits from Dallas, TX for 1890. Searching for influenza, grippe and catarrh gets some results:
                          http://freepages.history.rootsweb.an...s/obits90.html
                          Never forget Excalibur.
                          “‘i love myself.’ the quietest. simplest. most powerful. revolution ever.” ---- nayyirah waheed
                          Avatar: Franz Marc, Liegender Hund im Schnee 1911 (My posts are not intended as advice or professional assessments of any kind.)

                          Comment


                          • #14
                            While seven cases occurred during the first four months, as many as
                            fifteen occurred during the next four, and only two during the remaining
                            four months of the year. The preval- ence of the disease during May might
                            have been satisfactorily accounted for by the sudden and extreme
                            changes of temperature characterising that month. But the advent of
                            genial weather caused no diminution in the number of cases, as while
                            two occurred in April and four in May, as many as nine occurred in
                            the much warmer months of June and July. Nor did the direction of
                            the wind seem to have any appreciable influence. Coincident,
                            however, with this in-crease, the occurrence of unusual symptoms began
                            to attract my attention. Catarrh of one or more of the mucous surfaces
                            oficn pre- ceded, or even accompanied, the pneumonic
                            attack, while numbers of people—chiefly young—in the same neighbourhood, and
                            occa.sionally in the same house, as those affected with pneumonia, were seized with
                            these catarrhal symptoms, accompanied by pyrexia, but with no signs
                            of pneumonia.During that summer I attended more than twenty of
                            these latter cases,
                            -------------------------------------------------------
                            May 25th, wind west, [1886?]
                            mild;fine weather :left base ; recovery.
                            This boy was delicate, and became ill with what symptomatically might
                            be termed catarrhal fever or influenza.
                            A younger brother was at the same time similarly affected, both
                            the boys suffering from coryza, sore throat, cough, gastric catarrh, and pyrexia.
                            ------------------------------------------------------
                            June 12th, wind north-east, raw and cold ; right base ; recovery.
                            This boy was also seized with mild catarrhal symptoms,
                            -------------------------------------------------
                            There have thus been detailed three kinds of cases
                            1. Typical uncomplicated cases of pneumonia.
                            2. Uncomplicated cases of influenza or catarrhal fever.
                            3.Cases of pneumonia, preceded or accompanied by influenza,or catarrhal fever.
                            ------------------------------------------------
                            And even in these boys the influenza was the pri-
                            mary disease, and in the majority of cases the only one.The epidemie would
                            thus he more correctly designated "influenza" or"epidemic catarrh,"
                            ------------------------------
                            Dr.Mackenzie,Uist,late of Broadford, Isle of Skye [NW-Scotland], that, during the
                            end of 1882 and the first two months of 1883, that is, previous to
                            the outbreak here, an epidemic of influenza spread all over that island.
                            Thereafter, he attended nearly thirty cases of acute pneumonia,
                            all following, though after a longer interval than in my cases, attacks of influenza.
                            -------------------------------------------------------
                            Drumine is an alkaloid obtained from Euphorbia drummondii (Boiss).
                            Euphorbia drummondii, N.O. Euphorbiacese, has the following
                            botanical characters.
                            Uses.—In nasal catarrh, injected into the nostrils, it effects an immediate cure.
                            ---------------------------------------------------------------
                            He had investigated, for bacteria, a number of cases of .so-called "cold"
                            or catarrh, which had usually been ushered in with chilliness or shivering, sometimes amounting
                            to a rigor, and with a slight rise of temperature ; lassitude and more or less aching
                            of the body had boon complained of, with or without increase in the lachrymal
                            and nasal secretions.
                            ln all of these cases bacteria had been found to be present in the acute stage.
                            This fact was mentioned to suggest that probably the commonly related story
                            of having "caught cold," given as the cause of so many diseases, meant after
                            all not merely a chilling of the body as gener.illy understood, but
                            in many cases the reception of some morbid germ which had found an
                            environment.
                            ----------------------------------------------------------------------------
                            http://www.theodora.com/encyclopedia/i/influenza.html
                            [good summary from 1911, 32KB, 450 lines]
                            It is not clear whether the disease ever disappears wholly, and the deaths registered
                            in 1889 are the lowest recorded in any year since the registrar-general's returns began.
                            Occasionally local outbreaks of illness resembling epidemic influenza have been observed
                            during the period of abeyance, as in Norfolk in 1878 and in Yorkshire in 1887; but whether
                            such outbreaks and the so-called "sporadic" cases are nosologically identical with epidemic
                            influenza is open to doubt.
                            ---------------------------------------------------------------------

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                            Comment


                            • #15
                              emily, I wonder whether that "catarrhial fever" , mainly in children , before 1889,
                              which some called influenza or grippe, but which others, especially after 1890,
                              insisted should not be called influenza, whether that catarrhial fever or even
                              just catarrh (without fever) was indeed (often) some form of mild H1-influenza
                              with more respiratory ("catarrhial") symptoms and less muscle pain etc.

                              And whether that H1 maybe even survived summer in Europe.
                              And whether it was maybe also prevalent in horses (and dogs
                              or even other species)..
                              And whether that H1 was (almost) killed in 1890-1895 or reassorted
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