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29 instances only out of some 100 schedules. In all such instances in which the patient had lived for
a number of years in London, the diagnosis was more than doubtful; in the typical polioencephalitis
cases the patients were with three exceptions either young children or recent arrivals in London.
After June, the botulism theory had become generally discredited; a paper on Epidemic Encephalitis
appeared in the Lancet of 6th July, by Dr. S. A. Kinnier Wilson, which indicates the trend of opinion
at that date. Dr. Wilson regarded "the nervous disease now epidemic" as an encephalitis, and he
specified nine features which he suggested could be relied upon for distinguishing the cases observed in
the prevalence from sporadic cases of polioencephalitis. Dr. F. G. Crookshank in a letter to the
Lancet of 13th July, pointed out that the epidemiological question as to the relation between the epidemic
and sporadic cases is not entirely disposed of by the establishment of distinctions of the kind referred
to. A like criticism seems to apply to the criteria to which importance is attached on p. 4 of Sir Arthur
Newsholme's Report on the "Obscure Disease" to the Local Government Board. It is stated (p. 7
of that report) that " when the obj ect is to ascertain the nature of an illness, clinical and epidemiological
similarities between it and other diseases are of less value than differences." This is, of course,
a formula absolutely antithetic and polar to that of Creighton already quoted at the beginning of the
present report.
Dr. Wilson referred to Economo's cases of "encephalitis lethargica" in Vienna, but he said.
"sleepiness, lethargy or stupor may well accompany any form of encephalitis." He added: "it is not
clear we are dealing with an entirely new affection," and lie cited Chartier's monograph on a non-suppurative
encephalitis in Paris in 1907. He said, moreover, "in the acute encephalitis of influenza and in
numerous toxi-infective conditions it has long been recognised that symptoms may occur closely analogous
to those under review." He alluded, too, to a paper by Breinl on a "mysterious disease" occurring
in Queensland and New South Wales in 1917 and concluded that "what appears to be new is the occurrence
in epidemic form of cases of encephalitis, not to all appearance due to the action of a known
infective or toxi-infective agent, but presenting clinical symptoms, any or all of which have been noted in
various kinds of encephalitis with which the neurologist has long been conversant." In this connection
reference should be made to the paper "On some unusual forms of epidemic disease" by Chalmers,
Picken and MacLean, which appeared in the Lancet of 13th July, 1918. Chalmers mentions Picken's
suggestion that the Glasgow cases constituted an aberrant form of poliomyelitis similar to that presented
in the " lethargic encephalitis " of France.
So far as the presence of epidemic influenza in London was concerned, the question was finally
settled about the middle of June, when certain groups of cases of acute illness occurred. The first of these
was reported by Dr. A. E. Thomas on the 14th June. Dr. Pal grave ascertained that there were some
40 cases among girls in a mantle maker's establishment; severe frontal headache, pain in the eyes,
back and limbs with moderate pyrexia, were observed, and the illness lasted about three days,
leaving the patient depressed in mind and weakened in body. Dr. Brincker reported on the same day,
on a similar outbreak occurring in Chiswick, when he found in addition to the afore-mentioned symptoms
that sweating was common. On the 15th June, Dr. Hugh Dickson called and gave me full particulars
of an outbreak occurring in the staff of the Medical Officer of Customs at Newington Butts. The
symptoms described by Dr. Dickson were—" sudden onset with headache, feeling of extreme depression
and anger, fever, sore throat, muscular pains, marked sweating on first day of illness (some of the sweats
offensive), aching at the back of the eyeballs, cough, no rash, illness of two or three days' duration,
followed by marked depression."
The first
indication o
the appearance
of
influenza o
the type
familiar in
pandemic
prevalences,
Dr. Dickson who had wide experience of the last pandemic influenza (that of 1890) diagnosed
"acute influenza," and from that time forward all proffered suggestions as to the existence in London
of a supposed " new disease " were discarded. Dr. Dickson pointed out that with the exception of one
family, none of the patients had sought medical advice, and in the light of this and numerous subsequent
similar observations, there can be no doubt that the prevalence was very widespread; it may, indeed,
be further inferred that it was already widely diffused throughout London before any marked effect was
produced upon the weekly death-rate, and there can, further, be no question that the deaths from respiratory
diseases in January, and the mysterious pneumonias and stupors of the succeeding months, were
all part and parcel of the same epidemic prevalence. The reports concerning "botulism," while obscuring
the issues at the time, undoubtedly did good service in directing attention to a particular group of
symptoms, and in bringing to notice the fact that the symptom complex in question is apt to occur in
the development of a pandemic prevalence of influenza.
It is a striking fact that even during the height of the ensuing prevalence there was still
a curious disposition to attribute cases of undoubted influenza to other causes. Of this the following
instance may be given. On the 5th July an outbreak of illness was reported among children who had
gone on a "school journey," visiting a village a few miles out of London. In all, 9 of the 36 girls were
taken ill. The first two children attacked were held to have scarlet fever, the other 7 to have influenza.
Judged in the light of all the known facts no doubt can be felt as to the nature of the outbreak, but
there was considerable difficulty at the time in obtaining a hearing for the contention that influenza was
responsible for all nine cases.
It is now necessary to refer in detail to the three main epidemic waves of declared influenza,
the summer (June-July) and autumn (Oct.-Nov.) epidemics of 1918 and the epidemic of the first quarter of
1919. The weekly deaths from influenza, pneumonia and bronchitis are given in the accompanying
table:—
50129 H 2