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only very slightly. There were, however, numerous cases of mild influenza in London and the epidemic
continued to smoulder; then a second smaller wave of exceptional mortality swelled from about the
9th to the 18th weeks of 1918, in this the maximum number of deaths from bronchitis (153), was attained
in the 10th week and the maximum number from influenza in the 15th, (and during this period the
"obscure disease with cerebral symptoms," first began to attract attention). Furthermore, among
the deaths registered as due to pneumonia about this time there were certain grouped cases noted as
being of unusual character. Then a third wave of excessive mortality rose to its height from the 24th
to the 30th weeks; in this outbreak, to be referred to later as the summer prevalence of influenza, the
maximum number of deaths from bronchitis (74) and from influenza (287) occurred in the 28th week.
Suspicion that something new and special in the behaviour of influenza in London was in question
had in the first instance, been definitely aroused in December, 1917, on the occurrence of a sudden fatal
illness in a reformatory school boy. The death was attributed to "congestion of the lungs," and it
took place just prior to the time when the general death rate in London showed its first distinct rise.
Four further deaths occurred at intervals of some weeks, among boys from this same school; one on the
28th January, registered as due to "apical pneumonia," one on the 23rd February, due to "phthisis,"
one on the 12th April, attributable to cerebrospinal meningitis, and one on the 11th July, which was
registered as "influenza" at Wisbech where this disease was prevalent. These deaths must be regarded
with great suspicion; the signs found at the autopsies were obscure and the illnesses proved rapidly
fatal; the presumption naturally arose that they might be associated one with another, despite the
interval of time between the first and the last death.
The above outbreak resembles a number of others which have been recorded in industrial and
reformatory schools. Thus a similar prevalence was reported by Dr. A. MacLean in the Lancet (of
13th July, 1918) affecting three factories (420 cases) and an industrial school (16 cases) in Glasgow;
and Dr. MacLean refers further to a like outbreak attacking some 280 persons in two industrial schools,
a public school and a hosiery manufactory in the county of Lanark. "The greater number of cases in
the county presented the same symptoms,and there were 8 deaths, 7 from one industrial school and one
from another." These outbreaks further call to mind illnesses such as those recorded by Dr. J. B. Russell
in 1888 in a Glasgow industrial school, or that described in the Scottish Office Report on an outbreak
in St. Joseph's Industrial School, Tranent, in 1911. There is, moreover, an account of a similar outbreak
by Drs. McNeil and McGowan in the Edinburgh Medical Journal, 1913 (p. 201). In other institutions,
serious prevalences of pneumonia were recorded last year; one such instance was that referred to in a
report to the London County Council upon unusual mortality during 1918 at Claybury Asylum,. It is
further noteworthy that from the beginning of the year until May, Dr. Manby, of the Local Government
Board, was able to trace certain obscure illnesses among gipsies in Sussex, at first looked upon as cases
of pneumonia and then later regarded as typhus. (See Note on Typhus, Annual Report for 1918. Part I.)
The "obscure
disease
with cerebral
symptoms."
The impression that a special epidemic influence was at work was further confirmed by the occurrence
of a considerable number, some dozens, of cases presenting somewhat unusual cerebral symptoms.
Side by side with the ordinarily occurring cerebrospinal meningitis, of which there had been a few
examples each week throughout the early months of 1918, and of poliomyelitis of which a few were
notified from April onwards, there were cases developing symptoms (ophthalmoplegia, facial palsy,
etc.) indicative of polioencephalitis.
Attention was pointedly called to the fact by two papers in the Lancet of the 20th April, one
entitled "Acute Infective Ophthalmoplegia or Botulism" by Dr. Wilfrid Harris, the other "Toxic
Ophthalmoplegia" by Dr. Arthur J. Hall. The cases could not, in spite of the most careful enquiry
be connected with any particular article of food—they did not even affect persons who had partaken of
any common meal. Failing positive answers to enquiries as to sausages, tinned foods, etc., the suggestion
was made that potatoes might be at fault, but as to this no evidence was forthcoming. The
Local Government Board in a memorandum, issued in May, stated that the earliest traceable case of
the "obscure disease with cerebral symptoms," as it was agreed to call it provisionally, developed on
the 26th January, and it was officially declared that "no particular food has been found to be related
to the outbreak," and that there was "no bacteriological evidence of botulism. Dr. F. G. Crookshank
in a paper published in the Lancet of the 18th May claimed that the prevalence was really one of the
Heine-Medin disease, and in his opinion symptoms indicative of encephalitis, such as ophthalmoplegia,
had already been observed during the preceding year.
M. Netter in Paris had roted from early in March the frequency of cases with fever, somnolence
and ophthalmoplegia, and much comment was provoked in London by the occurrence of stupor in April
and May; it was even proposed that the term "epidemic stupor" should be applied to the "new
disease."
In conjunction with the Medical Officer of the Local Government Board a Schedule of Inquiry
as to cases of the " obscure disease with cerebral symptoms" was framed and upwards of 100 forms
were filled up by London medical officers of health, as a rule in consultation with one of the Council's
staff; for the most part the illnesses in question commenced from the second week in March up to
early in May; after that date involvemert of cranial nerve nuclei became, comparatively speaking,
rare. Some 30 or 40 cases of the bulbopontine form of encephalitis were thus brought to light, over
and above 20 or 30 others recorded in the medical journals. An analysis of the more typical cases,
those in which stupor and palsy of one or more cranial nerves were developed, showed that persons
of ages ranging from 3 to 43 were attacked, and that though the illnesses were alarming a fatal result
was not very frequent. The reports were full as regards the clinical and bacteriological details, but
only in a few instances were particulars as to associated illnesses recorded. Replies to an inquiry, as
to how long the patient had lived in the neighbourhood where the illness developed, were obtained in