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contrasts. The influenza death-rate of Berlin and Vienna in the 4 years 1919-1922
is little more than half that of London during the same period ; on the other hand the
rates for Copenhagen and Stockholm are Loth in excess of the London rate. The
New York and Chicago rates are lower than that of London, but Paris is lower
than either, and is not much higher than the rates of Berlin and Vienna. In some
cities which suffered severely in 1918 a comparatively low mortality from influenza
followed in the years 1919-1922. This was not the cause of the low post-war mortality
in Berlin, for in the pandemic of the autumn of 1918 the weekly death-rate from all
causes did not exceed 41.7 per 1,000, as compared with 55.5 per 1,000 of population
(in two successive weeks) in London. In Copenhagen, where influenza has been notifiable
for many years, the number of cases notified in the period 1918-1922 was over
three times that in the first five years of the nineties.
In the last Annual Report (vol. III., p. 45) reference was made to some of the
varied manifestations of influenza met with in 1920 and 1921 and particularly to
prevalence in London and in Manchester of the form of the disease accompanied by a
scarlatiniform rash. The Journal of the American Medical Association, 6th December,
1922 (p. 2,079), contains an account of "A scarlet fever epidemic in an agricultural
school." It is stated that "In February, March and April, 1922, 59 of the
840 students of this school in the University of Minnesota contracted scarlet fever.
Most of the students came from rural communities, 59 per cent. of them living in
places of less than 100 population. There was usually a rash and the cases were
frankly scarlet fever." There was, however, it transpires a "coincident epidemic
of influenza During February and March, while this section of the country
was experiencing an epidemic of mild influenza or 'grip,' 374 students of the University
contracted the infection, 182 of whom were admitted to the hospital as patients."
Of the hospital patients it appears 58 were students in the school of agriculture.
The outbreak recalls those commented upon in London and Manchester, and many
other outbreaks recorded in this country, in which influenza has shown a tendency
to manifest a scarlatiniform rash. The Journal of the American Medical Association,
12th May, 1923, further refers to a dengue epidemic in Galveston, Texas. "About
30,000 cases of dengue occurred in Galveston during the summer and fall of 1922
The diagnosis is made on 5 principal points (i.) sudden onset with fever and a chill
or chilly sensation ; (ii.) aching pains which may be generally localised in the head,
back or legs ; (iii.) suffused face and eyes; (iv.) normal or low leucocyte count with
a relative lymphocytosis; (v.) absence of jaundice and albuminuria. In addition
to these fairly constant symptoms there are usually noted (i.) soreness of the eyeballs
and skeletal muscles; (ii.) prostration and loss of appetite; (iii.) alteration of
taste. The symptoms should be confirmed by: (i.) the appearance of a toxic rash;
(ii.) termination of fever within 3 to 7 days and (iii.) the absence of any other disease
to explain the symptoms. Pregnancy was not disturbed. Convalescence was slow
and attended by a sense of weakness, fatigue and soreness of the muscles, which
lasted from 1 to 6 weeks." The diagnosis of a sudden supervention of 30,000 cases
with these symptoms, in this country, would, of course, have been influenza and not
dengue. In the above account of the outbreak the statement will have been noted
that the symptoms "should be confirmed" by the appearance of toxic rash and
absence of any other disease. Presumably the latter means disease affecting the
individual. If absence of any other epidemic disease had been the test appealed to,
the diagnosis of dengue would presumably have been upset, for there was widespread
influenza at the time specified. It will be remembered that early in 1922,
influenza was already prevalent in Europe; in January and February it was reported
in some of the larger cities in the United States; in March it was in the West Indies
and in New Orleans; in June and July South Africa became widely affected; it
had extended by the summer to the western states and continued to smoulder in
New Orleans through the autumn. "Dengue" has in times past been the name
applied in tropical countries to any sudden widespread prevalences of disease