Part 7

Chart VIII published by Sir Arthur Newsholme, showing the death rate per million of population from influenza in England and Wales gives some idea of the prevalence of the disease in the first part of the interpandemic period in those countries. It should be remarked that the record is for deaths from influenza only.

For records in this country it is convenient to refer to the death rate in the State of Massachusetts; first, because the records in that State have been carefully kept for a long period; and second, because influenza has been carefully studied in this State during both epidemics by two most competent epidemiologists. For the period preceding 1889 we quote herewith from Abbott:

“For the past 45 years or more, or during the period of registration which began with the year 1842, no epidemic of influenza has prevailed within the State to such an extent as to have manifested itself in any serious manner in the annual lists of deaths. An examination of the registration reports for each year since 1842 shows that in no year were recorded more than 100 deaths from this cause; the highest number from influenza in a single year (92) occurred in 1857, and the least number (8) in 1884. The average annual number of deaths from this cause reported in the State for the period 1842 to 1888 was 38. The average number during the first half of this period was greater than that of the last half, especially when considered with reference to the increase of population. From these statistics of nonepidemic influenza between the years 1842 and 1888 it appears that its greatest prevalence, or rather the years in which the mortality from this cause was greatest, were also years of unusual mortality from pneumonia, and in some instances from bronchitis.”

Frost has charted the death rate per 100,000 from influenza and from all forms of pneumonia in Massachusetts by month, from 1887 to 1916. From it he concludes that the epidemic of 1889–1892 developed in three distinct phases, the first culminating in January, 1890, the second in April and May, 1891, and the third in January, 1892. The mortality was higher in 1891 than in 1890, and still higher in 1892, while in 1893, although there was no distinct epidemic, the pneumonia mortality for the year was even higher than that of 1892. Frost remarks that this corresponds to the experience in England, and that it apparently represents the general experience in other countries (see charts IX and X).

CHART VIII.

CHART IX.

CHART X.

In the absence of comparable statistics for Massachusetts in 1917 and 1918, Frost has studied for those years certain other localities, particularly Cleveland, San Francisco and New York City. The mortality in all of these places, as well as in Massachusetts, was fairly regular from 1910 to 1915, but in December of the latter year and January of 1916 there occurred in New York and Cleveland a sudden sharp rise in mortality. This was not shown distinctly in the San Francisco curve, but it was a rise which was almost universal and synchronous over the entire registration area. It is of interest as indicating the operation of some definite and widespread factor, and suggesting in this group of diseases an epidemic tendency which is perhaps, as Frost remarks, not sufficiently appreciated. In January of 1916 he found that influenza was reported to be epidemic in twenty-two states, including all sections of the country. The epidemic was very mild. In the early spring of 1918 there was another sharp rise, which we shall discuss in greater detail later.

_Increase in 1900–1901._—Reference to Frost’s chart for Massachusetts shows that there was also a rise in the curve around 1900. At this time influenza was quite widely disseminated. Early in 1901 the Marine Hospital Service made a canvass of all the states and several foreign countries to determine the epidemic prevalence of influenza. The results of the canvass were published in the Public Health Reports. The records lack the detail, particularly in the description of clinical symptoms, that is desirable in arriving at an identification, but the universal agreement from all individuals reporting, in the comparatively high morbidity and remarkably low mortality, together with the widespread distribution, and the duration of the local epidemic leaves little doubt as to the identity.

Influenza was reported present in October of 1900 in Los Angeles, Milwaukee and New Orleans. In November it became prevalent in Toledo and Cincinnati and in New York City. In December the disease was present in Chicago, Albany, Philadelphia, San Francisco, Denver, Baltimore, Grand Rapids, Columbus, O., Portland, Me., Detroit, Albuquerque and Omaha. In January it was reported in New Haven, Boston, Washington, D. C., Indianapolis, Louisville, Ky., Wilmington, Del., Portland, Ore., and Juneau, Alaska.

Although the disease was mild, in some localities a high proportion of the population was attacked. Thus in New Haven it was estimated that 10 per cent. developed the disease, and in Los Angeles 20 per cent., while in Wilmington, 40,000 were estimated to have become ill. In certain small towns in Texas the incidence was especially high. In Pittsburgh, Texas, ten per cent.; Laredo, 15 to 20 per cent.; Hearne, 50 per cent.; and El Paso, 50 per cent. were attacked. The duration of the epidemic in most localities was from four to six weeks.

Thus we see that in October, November and December of 1900 and January of 1901 there was a widespread epidemic affecting all parts of the United States. Many additional records in the Public Health Reports coming from small towns have not been included in this summary.

At the same time an attempt was made to determine the prevalence in foreign countries and letters were sent to the various United States Consulates. It was discovered that the disease was mildly epidemic in Denmark in October, in Berlin in November, in Cuba, British Columbia, Ontario, Egypt, Paris, Mexico and the West Indies in December; in Flanders, Porto Rico, Honolulu, in January of 1901; in Malta in February, 1901; and in London and Ireland in March of that year. The following countries reported that they had no influenza at the time: Windward Islands, Jamaica, Bahamas, Brazil, India, Colombia, Costa Rica, Ecuador, Honduras, Persia, Philippine Islands, Spain, Switzerland. The disease was reported as being not of epidemic prevalence in the following localities: Marseilles, Paris, Bremen, Hamburg, Mainz, Stuttgart, Bristol, London, Liverpool, England as a whole, Scotland, Amsterdam, Naples, Constantinople.

Reports from Switzerland and from Brazil stated that there had been no influenza since the pandemic period 1889–1893. The death rate per 100,000 in Glasgow from influenza for 1896 was recorded as six; for 1897, twelve; for 1898, fifteen; 1899, twenty-two and for 1900, twenty-seven.

The disease was present in Lima, Peru in March, 1900, and at Malta in the same month. In Prague it was stated that ten per cent. of the population had been attacked in the winter of 1901. In Sivas, Turkey, fifty per cent. of a population of 50,000 were estimated to have been taken ill within the winter months. It was reported from Valencia, Spain, that there had been four or five visitations of influenza since the preceding pandemic, each recurring invasion presenting a milder and less expansive form than its predecessor. Very few deaths had been recorded as directly due to influenza, but an increased mortality followed the epidemics. In normal times the average mortality was ninety deaths per week. After a visitation of influenza the number had increased to as much as 160 per week. The population numbered 204,000.

_Period from 1901 to 1915._—Between 1900, with its wide distribution of a very mild influenza, and 1915, there is very little mention of epidemic prevalence of the disease. References which appeared in the Public Health Reports during the interval are characterized chiefly by their brevity, and by the absence of descriptive detail. They should nevertheless be included.

In October of 1901 there was some increase of the disease in the Hawaiian Islands, 110 cases being reported on the island of Kauai.

At the same time, C. Williams Bailey reported a mild form of influenza existing in Georgetown, S. C., which was first considered to be hay fever in consideration of the presence of the rice harvest season, but which was finally decided, after careful investigation, to be true influenza.

On July 21, 1902, the U. S. Consul at Canton, China, telegraphed that influenza “was almost epidemic, plague sporadic in Canton.”

In 1903 the disease was reported as apparently prevalent at New Laredo, Texas.

Surgeon Gassaway, of the Marine Hospital Service, reported from Missouri, December 14, 1903, as follows: “There is a very decided increase in the number of cases of influenza in this vicinity. Two have been admitted within the last few days to this hospital, and several cases have appeared among the patients under treatment. In these cases the onset is sudden and the disease appears principally, at least at first, to be confined to the nose and throat.”

Measles and influenza were reported prevalent in Barbados, West Indies, during the month of December, 1904.

Sturrock describes a quite typical local epidemic in a British institution in 1905.

Influenza was epidemic in Guayaquil and various other places in Ecuador during the months of June and July, 1906.

Selter speaks of a true local epidemic of a disease clinically resembling influenza which occurred in 1908 and extended over the territory from France to the Rhine.

Hudeshagen mentions having examined bacteriologically cases of influenza in the year 1914.

Ustvedt relates his experience at the Ullevaal Hospital up to September, 1918. Since 1890 there had been cases reported every year from the high marks of 10,461 cases in Christiania in 1890 and 5,728 in 1901 to the lowest figure, 138 in 1906. “The cases listed as influenza in the last few years may have been merely a catarrhal fever. This is the more probable as the cases were restricted to the winter months, while influenza usually occurs at other seasons.”

Jundell believes that influenza is endemic at Stockholm, Sweden, hundreds of cases being reported there each year. During the years 1912–1919 Pfeiffer’s bacillus has been found in ten per cent. of those cases in which the diagnosis seemed certain.

A current comment in the Journal of the American Medical Association in 1912 remarks that epidemics of coryza, sore throat, and bronchitis usually have been called influenza or grip because of the characteristic contagiousness and the infectivity, the persistence of the symptoms, and the tendency to prostration and mental depression. But this diagnosis has not been satisfactorily confirmed by bacteriologists. An epidemic according to the Journal, which occurred in Boston and which was called sore throat, was studied by Richardson and others. They traced the contagion to a streptococcus which apparently was spread by means of milk. Müller and Seligman had recently carried out a study of an influenza epidemic among children in Berlin and concluded that the causative organism was a streptococcus, differing so much from the ordinary germ that they used the term “grip streptococcus.” Davis and Rosenau, according to the comment, had made a bacteriologic study of a recent epidemic of sore throat in Chicago, and had demonstrated as the exciting agent a streptococcus of peculiar characteristics, which in many respects resembled the organism described by Müller and Seligman. The Journal noted that these three epidemics occurring during the years 1911 and 1912 in widely separated communities were all caused by the streptococcus, and cautioned against the proneness to call all such epidemics grip. Today the predominance of the streptococcus would not necessarily rule out influenza in our minds.

In the winter of 1913, C. L. Sherman had occasion to study carefully fourteen cases of so-called influenza in the vicinity of Luverne, Minnesota. Bacteriologic smears and cultures were made from the throat and sputum in all cases. Bacillus influenzae was found in two of the fourteen; pneumococcus in four and streptococcus in all. Tubercle bacilli were found in one case. The onset of the disease was invariably abrupt. The fever in all cases ranged between 101° and 104°; symptoms indicative of infection of the upper respiratory tract were always present. There was more or less sore throat in all. There was either cough at the onset or else it appeared within 48 hours. Headache was complained of by twelve of the fourteen; pains in the back and in the limbs by thirteen, and nervous symptoms by six. Prostration out of all proportion to the fever and other symptoms prevailed. Two developed an otitis media and the streptococcus was isolated from the purulent discharge in both cases. One patient had a complicating empyema, and one an acute arthritis. Sherman also concluded that we are prone to call too diverse diseases influenza.

Walb stated in 1913 that at Bonn during the preceding years there had been numbers of cases of a febrile affection which seemed to be typical influenza, but for which the pneumococcus appeared to be responsible. They were never able to isolate the influenza bacillus, and according to their statement the Hygienic Institute at Bonn, as well as that at Berlin, had not “encountered an influenza bacillus within the preceding ten years.”

C. T. Mayer described in 1913 a case of influenza in Buenos Ayres which is of particular interest in view of one of the symptoms, cyanosis, which was so prominent a feature in 1918. This appears to have been an isolated case. The diagnosis wavered between miliary tuberculosis and pneumonic plague, because of the high fever and intense cyanosis, with nothing to explain the cyanosis on the part of the heart. There were signs of severe congestion of both lungs, and notable enlargement of the spleen. Bacteriologic examination was negative except for the presence of Bacillus influenzae and Micrococcus catarrhalis. The patient subsequently improved rapidly, and the lungs were entirely normal after thirty days, thus ruling out the other two diseases.

A London letter to the Journal of the American Medical Association dated February 5, 1915, runs as follows:

“Since the outbreak of the war the public health has been remarkably good, but the record is now being threatened in the case of London, at any rate, by an epidemic of influenza.

“The gastric symptoms which distinguished last year’s epidemic are absent. The disease is most infectious. Whenever it has seized the individual it has usually run through the entire household.

“Whole offices have succumbed, and as the mildness of the attack lures the sufferer to continue his normal occupation, the disease has a full opportunity of extending. A large number have resulted in pleuro-pneumonia; otherwise the chief symptoms are headache, fever, tonsillitis.”

Telling and Hann describe another clinical diagnosis of influenza, the diagnosis being concurred in by Sir James Goodhart and Sir Clifford Allbutt. The onset was absolutely sudden at a supper party on November 10, 1912. The patient had a slight rigor, and was compelled to go to bed. In the night he had a longer and more severe rigor, with a temperature of 103°. On the following morning he dressed, but another chill sent him back to bed with a temperature still 103°, pulse 110, regular, and remarkably dicrotic. There was no cough and no sore throat. Another chill occurred in the evening. On November 12th the patient had two chills, the temperature remaining steadily at 103° to 104°. The patient complained much of nausea but did not vomit. On November 13th the temperature remained up, there was no chill on this day; the spleen was large and easily felt for the first time. On the 14th note was made that there was no headache. On the 15th, 16th and 17th the temperature began to fluctuate. On the 18th there were two severe rigors, and by the 19th the temperature suddenly fell to normal, with drenching sweat. Throughout there was nothing to suggest pneumonia, and typhoid fever appears to have been successfully ruled out.

An epidemic of influenza which prevailed in the city of Pittsburgh, Pennsylvania, from December to February of 1907 and 1908, has been described by J. A. Lichty. He says that the epidemic was as widespread, though probably not quite as severe, as the pandemic of 1889. Whole families, including servants and all associated with the household, were afflicted in rapid succession. The onset was sudden and severe, the usual symptoms of pain, all over, being most pronounced. The temperature did not go unusually high, nor did it seem to be in accord with the severity of the symptoms when the patient took to his bed. In typical cases the attack lasted from two to three or four days. Peculiar to this epidemic seemed to be the general complaint of sore throat. Upon examination the throat rarely showed any other evidence of an abnormal condition than a rather dark cyanotic blush, which was most intense over the tonsils and faded out over the roof of the mouth. This was rarely associated with any swelling or fever. Sinusitis and otitis media seem to have been the two most frequent complications. The disease appeared to be particularly fatal for chronic invalids. It was highly contagious. Many of those physicians who were frequently exposed to the disease fell victims.

At the same time C. H. Jones described an epidemic of the same disease in Baltimore. The symptoms were described as headache, backache, limb-ache, with a slight elevation of temperature, seldom more than 102°. Catarrhal symptoms developed secondarily and were not so prominent a feature as in former epidemics. There were some gastric symptoms, usually consisting of vomiting and nausea. Jones quotes no statistics, but feels sure that the infection was more extensive than at any period since 1895.

Coakley and Dench describe throat and ear complications as they saw them in New York. From this we may assume that the disease was present at the same time in New York City.

The following chart, derived from the U. S. Vital Statistics Report shows the increase in the death rates from influenza in 1900 and 1901; that of 1907 and 1908, and finally an increase to 26.4 per 100,000 in 1916, which reflects the epidemic beginning in the latter part of 1915:

_Influenza and Pneumonia Mortality in the United States Registration Area for Each Year Since 1900._ ═════════════════╤═════════════════════════════════════════════════════ Year. │ Annual death rates per 100,000. ─────────────────┼─────────────────┬─────────────────┬───────────────── „ │ Pneumonia. │ Influenza. │ Combined │ │ │ diseases. ─────────────────┼─────────────────┼─────────────────┼───────────────── 1900│ 158.6│ 22.8│ 181.4 1901│ 133.5│ 32.2│ 167.7 1902│ 124.7│ 10.1│ 134.8 1903│ 122.6│ 18.5│ 141.1 1904│ 136.3│ 20.2│ 156.5 1905│ 115.7│ 18.8│ 134.5 1906│ 110.8│ 10.3│ 121.1 1907│ 120.8│ 23.3│ 144.1 1908│ 98.8│ 21.3│ 120.1 1909│ 96.3│ 13.0│ 109.3 1910│ 147.7│ 14.4│ 162.1 1911│ 133.7│ 15.7│ 149.4 1912│ 132.3│ 10.3│ 142.6 1913│ 132.4│ 12.2│ 144.6 1914│ 127.0│ 9.1│ 136.1 1915│ 132.7│ 16.0│ 148.7 1916│ 137.3│ 26.4│ 163.7 ─────────────────┴─────────────────┴─────────────────┴─────────────────

At best our information for these years is unsatisfactory. It is greatly to be desired that individuals who have access not only to the current medical literature, but also to the vital statistics and other records for all countries possessing reliable records, and who are versed in the newer mathematical methods of demography, establish definitely the influenza prevalence and distribution during these interpandemic years. The difficulty in this work is that mortality statistics are unreliable and morbidity statistics are lacking.

_Influenza in 1915–1916._—Until the end of 1915 there was no widespread distribution in the United States similar to that of 1900 and 1901, but at that time there developed a widespread epidemic in this country of similar or possibly slightly greater severity than that of fifteen years previously. Reference to the last table will show that during 1916 the annual death rate from influenza as reported in the United States Vital Statistics reached the rate of 26.4 per 100,000. According to V. C. Vaughan the literature of that time shows that this epidemic originated in the West, first attracting attention at Denver, and gradually spread over the country.

Dr. Dublin of the Metropolitan Life Insurance Company gives the following table in which the deaths from influenza and pneumonia during the months of December, 1914, and January, 1915, are compared with deaths from the same cause during the months of December, 1915, and January, 1916:

═══════════════╤═══════════════════════════╤═══════════════════════════ Name of city │ Deaths reported as due to │ Deaths reported as due to │ influenza. │ pneumonia. ───────────────┼─────────────┬─────────────┼─────────────┬───────────── „ │ In 1915–16. │ In 1914–15. │ In 1915–16. │ In 1914–15. ───────────────┼─────────────┼─────────────┼─────────────┼───────────── Baltimore │ 57│ 12│ 219│ 101 Cincinnati │ 81│ 2│ 105│ 84 New Orleans │ 97│ 44│ 35│ 29 New York │ 494│ 62│ 2,067│ 1,207 Philadelphia │ 324│ 62│ 564│ 272 Providence │ 38│ 3│ 31│ 31 ───────────────┼─────────────┼─────────────┼─────────────┼───────────── Total │ 1,091│ 185│ 3,021│ 1,724 ───────────────┴─────────────┴─────────────┴─────────────┴─────────────

Dublin states that the Industrial Department of the Metropolitan Life Insurance Company, covering the entire country and embracing ten millions of people, had deaths in the periods above mentioned, as follows:

In December, 1914, and January, 1915, the number of deaths attributed to influenza was 165

While in the corresponding months of 1915–1916 the deaths attributed to influenza were 957

The deaths attributed to pneumonia in December, 1914, and January, 1915, were 1,468