The earliest 1918 pandemic “influenza” case report?

King Alfonso of Spain appears to be the first case reported in the newspapers in May 1918 followed by several cases in the medical press including a case series of fifty in July 1918 in the BMJ.

I’ve been looking for the earliest case reports of the flu in 1918 which seems to have first been reported in San Sebastian, Spain in February 1918 – hence the name Spanish flu. However, it probably originated somewhere else.

There are cases reported in Fort Funston, Kansas in March and on the Western Front in French and British soldiers in April1. A Sergeant John Acker said that the troops called it “three day fever”2.

There is much debate in the medical journals at this time of “trench fever” and “weak heart” and a good number of obituaries with influenza as a cause of death.

In June the BMJ is prompted to respond to the newspaper reports of King Alfonso’s illness – a third of Madrid are ill by this time. In the article it says, “We cannot help feeling that in the absence of any bacteriological proof, the extreme low mortality or its practical absence, and the possibility that the disease is gastro-intestinal influenza, render alarmist suggestions premature, and they do not seem to be countenanced by the medical profession in Spain” and went on to say that influenza was the probable cause. 3

The following week the BMJ updated the story saying, “The widespread epidemic of an acute catarrhal affection in Spain, which was stated in our last issue to be most probably influenza and attended by little or no mortality, is now reported to have caused 700 deaths in ten days, but if the number of cases has been as large as reported the case mortality must have been very low.”4

The first published cases in the BMJ come in the form of a case series of the first fifty cases at the Central Royal Air Force Hospital, Hampstead from July 1918. It contains useful advice on the presentation, comparison with physical signs from the 1889 pandemic, fever charts, differential diagnosis and the practical management of cases.5

What I find interesting is how the reporting seems to have mirrored the current pandemic. At the beginning there is doubt over the diagnosis, the debate on case fatality rates and whether it would be as severe as the previous pandemic, and later it focusses on the clinical management of cases and health policies. I hope the 2009 pandemic will not continue to mirror the 1918 one and become more deadly in late 2009 through 2010.

Remember to keep up to date with the current swine flu at the pandemic flu blog.

1) Tucker S (Editor). “Influenza Pandemic (1918 – 1920)” in “World War I a student encyclopedia”. ABC-CLIO, 2006.

2) Kolata G. Flu: the story of the great influenza pandemic of 1918 and the search for the virus that caused it. Touchstone, 2001.

3) No author listed. The reported epidemic in Spain. Br Med J 1918;1:627.

4) No author listed. The reported epidemic in Spain. Br Med J 1918;1:653.

5) Gotch OH, Whittingham HE. A report on the “influenza” epidemic of 1918. Br Med J 1918;2:82-85.