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The outbreak which has recently aroused much attention had doubtless been brewing since the
end of 1917. As early as December of that year certain anomalous cases of suddenly appearing stupor,
in which suspicion arose as to pneumonia, cerebrospinal meningitis, typhus, etc., were noted ; and there
can be no doubt that during the early months of 1918 in addition to the ordinarily occurring influenzas
of the winter season there were numerous attacks of unusual severity in which much difficulty arose
as to diagnosis from typhus and spotted fever, from encephalitis, cerebrospinal fever and acute
pneumonia. The Lancet, of April 7, 1918, published two papers in which the "new disease" was
declared to be botulism, and later other articles of food than sausages were held to be suspect. There
was at no time, however, any actual evidence pointing to food origin of the outbreak, and it speedily
became clear that the prevailing type was a polioencephalitis of the kind described in recent years by Wickman,
Brorstrom, and many others, as occurring in association with outbreaks of acute poliomyelitis.
But here, again, the "posting character" of the prevalence, the creation of the impression of its being
a "new disease" * and its "protean manifestations" were all to hand; and the association of cases of
polioencephalitis in the early stages of the outbreak with cases of influenza, bronchitis and pneumonia,
and later with cerebrospinal fever and poliomyelitis, can leave no doubt but that the prevailing epidemic
was identical with all the other posting and protean "new diseases" of the last five centuries, in fact
with what, in the absence of knowledge of its essential cause, can perhaps best be described as the influence
—influenzaf.
It should be noted as a question of possible importance that at the time when a pandemic
prevalence of influenza might perhaps have been forecasted in this country, in the light of the epidemiological
history, the number of persons landing from abroad was to a large extent limited to soldiers or
to persons engaged on special military duties. Thus, the place of the large numbers of civilian migrants
and transmigrants coming to London at the time of the last pandemic, 1889-90, has been for the
most part filled by Colonial and more recently by American soldiers; there has been in addition, of
course, the arrival of men on leave from the front and of wounded. The question arises, therefore, as
to whether the recent epidemic influence has in the main been derived from the east or the west. As
regards the former, little had been heard up to May of influenza on the continent, though that disease
and polioencephalitis are said to have prevailed in Germany and recent accounts are forthcoming of
influenza from Spain and of polioencephalitis from Paris ; furthermore some suspicion may attach to
the " pyrexias of unknown origin "and perhaps to some of the cases ascribed to "trench fever" among
British troops. It is in particular deserving of note in this connection, that according to a recent paper
by Captains Sundell and Narkivell, in the Lancet, March 16, 1918, three types of onset of trench fever are
observed: "1 General, with prostration, etc.; 2. Abdominal; 3. Cerebrospinal. This last type forms
roughly 1 per cent. of the cases." This classification applied to a "new disease" at least arouses some
suspicion. As regards origin from the west, it is known that in New York in 1916 there was a considerable
prevalence of poliomyelitis, and for some time before this, cerebrospinal meningitis was reported
from the States and from Canada ; it may be, therefore, that infection has been transmitted preponderatingly
from the west during the war period and that this fact is in part responsible for the special
type of disease hitherto observed here. (See footnote +).
An examination of the recorded outbreaks of influenza in this country shows, however, that when
the epidemic has prevailed in the spring and summer, cases of nervous type have predominated. Thus,
in 1658, in April, there was " much cephalic affection," followed in the summer by a new fever in which
the sufferers were " ill in their brain and nervous stocks." Creighton notes that " spots " were commonly
observed, and that "those who died passed away in a stupor." lie says the account given of the
exanthem "reminds one rather of the rash of sweating sickness and of dengue (break bono fever) than of
the spots of typhus." Again in 1710, 1743, 1767, 1803, 1831 and 1833, great epidemics prevailed in the
spring and "nervous disturbance* and "affection of the head" predominated. It will be seen,
therefore, that the present type of epidemic prevalence (May, 1918) is in no way aberrant, though it
differs from the respiratory type of influenza obtaining in winter with which the present generation of
practitioners is especially familiar.
Cerebrospinal
meningitis.
During 1917, 430 cases of cerebrospinal fever and post basic meningitis were notified in London
including 25 military cases. Of these 38 proved subsequently not to be cases of cerebrospinal
meningitis. On the other hand, 15 cases came under observation, which were not officially notified.
Thus 382 actual cases were known to have occurred during 1917 among the London civilian population,
of which 227 proved fatal.

* Epidemics of influenza have generally taken the world by surprise and they have been initially described as
"new disease," "new delight," "new acquaintance," or in the older phraseology as "stop gallant," "stop, knave, and
know thy master," etc.; or, again, recently as the "mystic disease," or "a new and strange outbreak the germ of
which has not yet been discovered."
† Since writing the above, the question has been decisively cleared up by the widespread occurrence of groups of cafes
of influenza of the type commonly observed in the great prevalenco of 1889-90.