epidemic until the commencement of the new year. In London the full onset of unmistakable influenza dated from the 1st of January 1890. Everywhere it seems to have exhibited the same explosive character when once fully established. In St Petersburg, out of a government staff of 260 men, 220 were taken ill in one night, the 15th of November. During January 1890 the epidemic reached its height in London, and appeared in a large number of towns throughout the British Islands, though it was less prevalent in the north and north-west than in the south. January witnessed a great extension of the disease in Germany, Holland, Switzerland, Austria-Hungary, Italy, Spain and Portugal; but in Russia, Scandinavia and France it was already declining. The period of greatest activity in Europe was the latter half of December and the earlier half of January, with the change of the year for a central point. Other parts of the world affected in January 1890 were Cape Town, Canada, the United States generally, Algiers, Tunis, Cairo, Corsica, Sardinia, Sicily, Honolulu, Mexico, the West Indies and Montevideo. In February the provincial towns of England were most severely affected, the death-rate rising to 27.4, but in London it fell from 28.1 to 21.2, and for Europe generally the back of the epidemic was broken. At the same time, however, it appeared in Ceylon, Penang, Japan, Hong Kong and India; also in West Africa, attacking Sierra Leone, and Gambia in the middle of the month; and finally in the west, where Newfoundland and Buenos Aires were invaded. In March influenza became widely epidemic in India, particularly in Bengal and Bombay, and made its appearance in Australia and New Zealand. In April and May it was epidemic all over Australasia, in Central America, Brazil, Peru, Arabia and Burma. During the summer and autumn it reached a number of isolated islands, such as Iceland, St Helena, Mauritius and Réunion. Towards the close of the year it was reported from Yunnan in the interior of China, from the Shiré Highlands in Central Africa, Shoa in Abyssinia, and Gilgit in Kashmir. In the course of fifteen months, beginning with its undoubted appearance in Siberia in October 1889, it had traversed the entire globe.
The localities attacked by influenza in 1889–1890 appear in no case to have suffered severely for more than a month or six weeks. Thus in Europe and North America generally the visitation had come to an end in the first quarter of 1890. The earliest signs of an epidemic revival on a large scale occurred in March 1891, in the United States and the north of England. It was reported from Chicago and other large towns in the central states, whence it spread eastwards, reaching New York about the end of March. In England it began in the Yorkshire towns, particularly in Hull, and also independently in South Wales. In London influenza became epidemic for the second time about the end of April, and soon afterwards was widely distributed in England and Wales. The large towns in the north, together with London and Wales, suffered much more heavily in mortality than in the previous attack, but the south-west of England, Scotland and Ireland escaped with comparatively little sickness. The same may be said of the European continent generally, except parts of Russia, Scandinavia and perhaps the north of Germany. This second epidemic coincided with the spring and early summer; it had subsided in London by the end of June. The experience of Sheffield is interesting. In 1890 the attack, contrary to general experience, had been undecided, lingering and mild; in 1891 it was very sudden and extremely severe, the death-rate rising to 73.4 during the month of April, and subsiding with equal rapidity. During the third quarter of the year, while Europe was free, the antipodes had their second attack, which was more severe than the first. As in England, it reversed the previous order of things, beginning in the provinces and spreading thence to the capital towns. The last quarter of the year was signalized by another recrudescence in Europe, which reached its height during the winter. All parts, including Great Britain, were severely affected. In England those parts which had borne the brunt of the epidemic in the early part of the year escaped. In fact, these two revivals may be regarded as one, temporarily interrupted by the summer quarter.
The recrudescence at the end of 1891 lasted through mid-winter, and in many places, notably in London, it only reached its height in January 1892, subsiding slowly and irregularly in February and March. Brighton suffered with exceptional severity. The continent of Europe seems to have been similarly affected. In Italy the notifications of influenza were as follow: 1891—January to October, 0; November, 30; December, 6461; 1892—January, 84,543; February, 55,352; March, 28,046; April, 7962; May, 1468; June, 223. Other parts of the world affected were the West Indies, Tunis, Egypt, Sudan, Cape Town Teheran, Tongking and China. In August 1892 influenza was reported from Peru, and later in the year from various places in Europe.
A fourth recrudescence, but of a milder character, occurred in Great Britain in the spring of 1893, and a fifth in the following winter, but the year 1894 was freer from influenza than any since 1890. In 1895 another extensive epidemic took place. In 1896 influenza seemed to have spent its strength, but there was an increased prevalence of the disease in 1897, which was repeated on a larger scale in 1898, and again in 1899, when 12,417 deaths were recorded in England and Wales. This was the highest death-rate since 1892. After this the death-rate declined to half that amount and remained there with the slight upward variations until 1907, in which the total death-rate was 9257. The experience of other countries has been very similar; they have all been subjected to periodical revivals of epidemic influenza at irregular intervals and of varying intensity since its reappearance in 1889, but there has been a general though not a steady decline in its activity and potency. Its behaviour is, in short, quite in keeping with the experience of 1847–1860, though the later visitation appears to have been more violent and more fatal than the former. Its diffusion was also more rapid and probably more extensive.
The foregoing general summary may be supplemented by some further details of the incidence in Great Britain. The number of deaths directly attributed to influenza, and the death-rates per million in each year in England and Wales, are as follow:—
It is interesting to compare these figures with the corresponding ones for the previous visitation:—
The two sets of figures are not strictly comparable, because, during the first period, notification of the cause of death was not compulsory; but it seems clear that the later wave was much the more deadly. The average annual death-rate for the nine years is 320 in the one case against 162 in the other, or as nearly as possible double. In both epidemic periods the second year was far more fatal than the first, and in both a marked revival took place in the ninth year; in both also an intermediate recrudescence occurred, in the fifth year in one case, in the sixth in the other. The chief point of difference is the sudden and marked drop in 1849–1850, against a persistent high mortality in 1892–1893, especially in 1892, which was nearly as fatal as 1891.