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per cent. of the population were attacked in the summer and 10.4 per
cent. during the autumn and winter.
Frost found in his survey of 130,033 individuals that the
percentage of the population attacked varied from 15 per cent. in
Louisville, Ky., to 53.3 per cent. in San Antonio, Texas, the aggregate
for the whole group being about 28 per cent. He remarks that this
agrees with scattered observations in the first phase of the 1889–
1890 epidemic, when the attack rate seems to have varied within
these limits. In five of the localities studied, geographically widely
separated, the incidence rate varied only within a narrow limit, from
200 to 250 per thousand. Variations in attack rate showed no
apparent consistent relation to geographic location or size of
community, or to the rapidity of development of the epidemic.
In a house-to-house survey of 10,000 individuals in Boston the
author found that in the winter of 1918–19, 19.71 per cent., or one-
fifth of the entire population had developed the disease. It should be
pointed out that while the standards used in this survey are entirely
comparable to those used by Frost, the author has, contrary to
Frost’s method, not included in his group of positive cases those
classified as “doubtful.” This would raise the total incidence to a
certain extent, but we feel convinced that by omitting the doubtful
cases we have approached nearer to a correct picture of the epidemic
as it actually occurred. As will be seen from Chart XVI there was no
great variation in the different districts studied, with the exception of
Districts IV and V. Districts I, II and III were in the tenement section
of the city, while District VI was in one of the finest residential parts
of Brookline. Districts IV and V were midway between these two
extremes as regards economic and sanitary status, as well as extent
of crowding. The lowest incidence was in the Irish tenement district.
The highest in a middle class Jewish population.
CHART XV.
 CHART XVI.

In the 1920 recurrence we found that 9.55 per cent., or one-tenth

of the entire population, suffered from the disease, and the
arrangement of districts in order of incidence was very little changed.
The Irish community suffered least; the two middle class
communities most. The well-to-do district in Brookline had the next
lowest incidence in 1920. That the high recorded incidence in middle
class districts was not due to more accurate or more thorough work
on the part of the inspectors is indicated by the fact that a great part
of the work on Districts IV and V was done by the same individuals
who inspected Districts II and III.
 One-fifth of the population studied developed the influenza in
1918–19, and one-tenth of the same population suffered in 1920.
We may agree with Winslow and Rogers, who conclude that the
proportion of the population actually affected by the influenza
epidemic in 1918 varied between 200 and 400 per thousand.
Relation of sex to morbidity.—Abbott concluded from his studies
in 1890, that the weight of testimony appears to favor the statement
that persons of the male sex were attacked in greater number and
with greater severity than females. Leichtenstern reached similar
conclusions. In the epidemic of 1889, the males were attacked more
frequently than the females. He attributes this to two causes: first,
the greater exposure to infection, and; second, the fact that strong,
robust individuals are more frequently attacked.
It is amusing to compare this explanation with another found in
the Medical Supplement to the Review of the Foreign Press for
March, 1919. “A Spanish mission composed of Maranon, Pittaluga
and Falco visited Paris last October to collect information as to the
identity of the Spanish epidemic with the world pandemic of
influenza. They found that the epidemics in France and Spain were
absolutely identical from the epidemiologic, bacteriologic and
clinical standpoint. The great majority of the severe cases in both
countries occurred between the ages of 16 and 40. Both in France
and Spain more females than males were attacked, which was
possibly explained by the greater tendency of the former to lead an
indoor existence.”
Jordan, Reed and Fink, working in Chicago, found very different
results. They could discover no noteworthy difference among the
pupils in high school and elementary school. The attack rate was 230
for the boys and 231 for girls. One sex was presumably as much
exposed as the other.
Among the employees of the Chicago Telephone Company, on the
other hand, the men were affected in considerably lighter proportion
than the women (151 per 1,000 as compared with 233 per 1,000 for
women). Jordan believes that the age factor was largely responsible
for the difference as the women employees are as a rule of much
lower average age than the men.
 Frost found that with few exceptions the attack rate at all ages was
somewhat higher in females than in males. The total excess of
incidence in females was six per cent., which ranged from an excess
of nineteen per cent. in the highest locality to a deficiency of two per
cent. in the lowest. Only two of the eleven localities surveyed showed
a lower incidence among females than among males.
When the sexes were compared in different age groups, the female
was found to be higher than the male in each age period except
under 5, 10 to 14, 40 to 44, and 70 to 74. The excess of incidence in
males in these groups is relatively small, and is hardly significant in
the highest age groups, where the rates are computed from small
figures. Frost found the most striking excess of incidence in females
occurring between the ages of fifteen and forty, the difference
between the sexes being relatively slight in age periods above and
below these limits. Females over the age of fifteen and especially
between the ages of 15 and 45 were either more susceptible to
infection, or more generally and more intimately exposed than males
of corresponding age.
Our own records by the different age groups were remarkably
similar. We have found an excess among the females in every age
except under five years, 10 to 14, 50 to 54, and 60 to 64. In 1920 we
found a slight excess among the males up to the age of 15, and again
at the ages 55 to 65. Females predominated in all other ages (Chart
XVII). Among those individuals who had attacks of influenza during
both epidemics females again predominated except in the ages under
5 years, 10 to 14 and 55 to 59. In our own results we find that ages
above 65 show a predominance of females.
After considering both series of results it is safe to generalize in
saying that above the age of 15 the female sex tends to acquire the
disease in slightly greater proportion than the male sex.
Chart XV shows the predominance of the female incidence in both
epidemics.
CHART XVII.
CHART XVIII.
CHART XIX.
CHART XX.
CHART XXI.
 Relationship of sex to severity.—In classifying cases as to severity,
we have followed the standard previously described. Our results have
shown that the 1920 recurrence in our group of individuals has been
decidedly milder than the earlier 1918 spread. The proportion of mild
cases in 1920 is nearly twice that of mild attacks in 1918–19. The
proportion of severe cases was twice as great in 1918 as in 1920. The
actual severity in 1918 was even greater than would be indicated by
these figures. The last column in Chart XVIII is a combination of the
two preceding, and while the 1920 column includes all classed as
severe, pneumonia, and fatal, that for 1918 only includes the severe
and pneumonia cases, but does not include the fatal cases for that
year, because those who died during the 1918–19 epidemics are not
counted in our 10,000 individuals surveyed. If these were included
the percentage of total severe, or average severity would be greater
than 42.70.
 We find that in 1918 the female sex had a higher proportion of
severe cases according to our standard than did the male. This was
equally true in 1920. We should emphasize here that we are not
comparing only the fatal cases in the two sexes, but all classified as
severe, and including fatal in 1920.
Not only was the female sex attacked in slightly greater proportion,
but also the individual cases appear to have been on the aggregate
somewhat more severe in that sex.
Morbidity by age.—Before discussing the incidence of influenza in
the various age periods we should explain that the charts for 1920
are based on the ages given by the individuals, and those for 1918
upon these ages, corrected by the subtraction of 15 months from the
age as given. In our study of cases recurring during both epidemics
the age used in the calculations is that of 1920. It is for this reason
that in all of our age charts we have a first age period from zero to 15
months. Infants of less than 15 months at the time of our survey were
born subsequent to the peak of the 1918–19 epidemic, and are not
included in computations for that time.
The general similarity of the age incidence in the six districts
studied (Charts XIX and XX) is evident. As a rule two peaks can be
discerned, one falling somewhere between 15 months and 9 years,
and the other between 20 and 39 years. There are individual
variations in the different districts, and in Districts IV, V and VI
there is a tendency toward a peak in the period 55 to 64. This,
however, disappears when the total 10,000 is tabulated, when the
two peaks, 15 months to 9 years, and 20 to 39, show out clearly for
the year 1918 (Chart XVII).
Frost found for the same epidemic that the attack rate was highest
in the age group 5 to 9, declining with almost unbroken regularity in
each successive higher age group, with the exception of the groups 25
to 34, in which the attack rates were higher than in the age groups 15
to 24, but not as high as that of 5 to 9.
Both series of observations agree in finding relatively high
incidence in early childhood and in early adult life.
For 1920 (Chart XVII) we find that these peaks, although present,
have become decidedly less prominent, and that there is a relatively
higher incidence in individuals past the age of 40 (Charts XXI and
XXII). There is some tendency toward straightening out of the curve;
age appears to have played a less important part, and those higher
ages which were relatively insusceptible in 1918 have become more
susceptible in 1920. We cannot generalize in the statement that all
ages which were lightly attacked in the first epidemic were more
severely attacked in the 1920 spread, because the ages from 10 to 19
are found to be relatively lower during both epidemics.
Other observations have been made regarding the age incidence
particularly during the 1918 pandemic. Jordan’s figures for the
October epidemic show a higher incidence among school children of
ages 4–13 than among those of higher school age, 14–18. The
teachers in these schools had a lower attack rate than the pupils. The
pupils in both school groups were from the same section of the city
and to a large extent from the same families and were presumably
exposed in similar degree.
Lynch and Cumming found that of 49,140 children in public
institutions the influenza rate was 412 per 1,000, while among
703,006 adults in similar institutions the rate was 263 per 1,000.
These figures include children in a large number of institutions
scattered throughout the United States, and would indicate that in
childhood the susceptibility is much greater than in adults.
Many writers agree that nursing infants show a relative
insusceptibility. However Abt records a case of an expectant mother
who, within two weeks of term, developed influenza, and during the
course of her illness gave birth to a baby boy, who at birth was found
to be suffering from bronchitis and bronchopneumonia, but who
lived for three days, finally dying of bronchopneumonia. Abt
concludes from a review of all of the facts that the newly born infant
had influenza and that the baby had become infected before birth.
CHART XXII.
 According to Carnwath, the age incidence showed curious changes.
During the 1918 summer wave the ages most affected were 15 to 45.
In the winter of 1918–19 there was a considerable shifting toward the
extremes of life and particularly toward the younger years. The
susceptibility of young children was the subject of a special inquiry in
London. Though the attack rate was below the average, the chances
of recovery were less than in other age groups. Of breast-fed infants,
30 per cent. contracted the disease; of artificially-fed 54 per cent.
The opposite, however, occurred in lying-in homes. An inquiry in
Cheshire revealed that 25.4 per cent. of expectant mothers affected
died.
Renon and Mignot have made a report on the 1920 recurrence.
According to them the grip of 1920 attacked all ages, in
contradistinction to the 1918 epidemic, which attacked especially the
young and vigorous. One-third of their group were over 40 years of
age, while some were 70 and 80 years old. In spite of this the disease
remained relatively mild.
Age morbidity in previous epidemics.—Previous to the epidemic
of 1889–93, the various recorded observations regarding morbidity,
and particularly regarding age morbidity, have consisted often of
records made by practising physicians, and are merely estimates
based upon their clinical experience and varying with the type of
individual treated by them. Or else they have been records made by
non-medical historians. During the 19th century, the tendency
toward statistical enumeration becomes more and more prominent,
but the first statistical studies of real value to the epidemiologist
were made in the epidemic of thirty years ago. Statistical study must
begin with this last epidemic. Observations of the earlier epidemics,
while very interesting for reference and comparison, are no longer
acceptable as unquestioned statements of fact. Even at the present
time and with all of the emphasis that is now being laid upon
statistical procedure the records are far from perfect, and it is to be
hoped that in years to come the improvement will be so decided that
the records even of the 1918–20 epidemics will appear crude.
Buoninsegni remarks of the 1387 epidemic that many individuals
of all ages died, but the deaths were particularly prevalent among the
aged.
Jacob, of Königshofen, writes that “there came a general pestilence
in the whole country, with cough and influenza, so that hardly one
among ten remained healthy,” and that old and debilitated persons
were frequently the victims.
Balioanus tells us that the epidemic of 1404 let not rank, age nor
sex escape its effect.
In 1557, according to Valleriola, the disease appeared with
pestilential rapidity, and spared neither sex, nor any age, nor rank,
neither children nor old persons, rich nor poor, but that it was not as
a general rule dangerous; children only, who could not freely cough
out the phlegm, dying.
The same story is told by Molineux, for 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.” Molineux, however, added that, “it rather favored the very
old who seldom were attacked with it.”
These observations are but broad generalizations; if we pause to
study the psychology of the historian we are tempted to conclude
that his primary object was to impress his readers with an idea of the
enormousness of the dissemination of the disease during his period.
That being the main endeavor, a tendency to exaggerate for the sake
of rhetoric and yet remain within the limits of truth may be
considered excusable. But during the 1889–93 epidemic there was
ample opportunity to compare the estimates made by the practising
physicians with the later statistical tabulations. As a rule the former
were higher both as regards morbidity and mortality.
In the 1830–32 epidemic an interesting observation has been
made. While Kahlert says that no distinction between age, sex nor
rank occurred, Leberscht stated that persons of middle age,
especially women in the climacteric period, were attacked with
special frequency. This is of interest in view of the findings in the
1918 epidemic. Krimer states for the same epidemic that children
under 14 years of age and adults over 45 years were spared by the
epidemic.
For the 1836–37 epidemic Finkler records the following: “Most of
the patients were adults from 20 to 40 years of age, and of these
more women than men were attacked. Curiously, however, the
physicians of Würtenberg speak of the great dissemination of the
disease among children.”
In 1847–48, among the adult influenza patients, there are said to
have been more women than men. According to Canstatt, there were
proportionately more children than adults attacked.
In 1889–90, according to Finkler, no age was spared, but persons
between 20 and 50 years of age were attacked by preference. No
trade was a sure protection. The course of the disease in general was
favorable and also quite rapid, unfavorable only in many children
during the first few years of life, in many old people, in many
debilitated persons, and especially in those suffering from chest
affections.
 An interesting table of this kind is given us by Leichtenstern. His
hospital material included 439 influenza patients, and these he
carefully grouped according to age.

Influenza admissions, General average of

Age.
per cent. admissions, per cent.
Under 10
0.9 0.7
years
10–20
14.7 8.8
years
20–30
40.3 27.5
years
30–40
19.1 23.3
years
40–50
10.1 15.7
years
50–60
7.4 12.3
years
60–70
5.3 8.9
years
70–80
1.7 2.6
years
Above 80
0.4 0.2
years

Comby found that in Paris only the new-born were noticeably

insusceptible to influenza, that children up to 15 years were attacked
in the proportion of 40 per cent., and adults in the proportion of 60
per cent. 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 per cent.) 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: