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APPENDIX III.
CEREBRO-SPINAL FEVER IN LONDON DURING 1909.
With regard to the occurrence of cerebro-spinal fever in London during the year 1909, there
is again little of importance to record. There has been nothing approaching epidemicity. III cases
were certified. In addition there were 12 cases diagnosed during life and not certified, and 16 other
cases only diagnosed at death and not certified. Thus 139 cases in all occurred in London.
It is noteworthy that there was a rise in the figures in March. This requires comment, lest
hereafter the figures should be thought to support some causative influence which was, in fact,
non-existent. The following table shows the character of the rise:—

For most of the year, as will be seen, from 0—3 cases occurred every week. But in the
eleventh week, viz., that beginning on 14th March, the figures suddenly rose to 8, remained thereabouts
for seven weeks, and then fell to normal again. It might well be thought that there had been a slight
outbreak and that possibly some climatic influence had been operating. But this was not the case.
The cases were scattered about London, and no sort of grouping or connection could be traced. At
the same time it is clear that 50 notifications, nearly one half of those received during the whole year,
were received during these seven weeks. The explanation may be found in the following circumstance.
During the week preceding this rise, a circular was sent by the Clerk of the Council to every medical
practitioner in London, informing them that cerebro-spinal fever was made notifiable for a further period
of twelve months. It is in accord with experience that when the attention of the medical profession
is strongly directed, in this or in other ways, to the possibility of any particular disease being prevalent,
notifications of that disease are apt to increase. This appears to have been the case in the present
instance. Such a reminder appears to act in the way of suggesting to medical practitioners the
question " Can such-and-such a case be cerebro-spinal fever ? " a question which usually is not so vividly
in mind.
The certified cases were inquired into by the respective medical officers of health of the district,
and the inquiries were followed up by myself. I endeavoured to ascertain the origin of every case and
what factors bore on its causation. In this connection I interviewed the friends or relatives of nearly
every patient and where necessary the medical attendant. Commonly the patients were in hospital.
Inquiry was made into the previous history of patients and into the history of the parents and
the family, particularly whether similar cases had occurred previously in the family. Attention
was also directed to the condition of the mucous membranes of the patients ; and to the association
of their disease with other diseases ; and to a number of other points which might possibly throw
light on the causation of this disease. No single circumstance was found which would suggest that
any one verified case had had any connection with any other, nor was there evidence of any common
cause acting. In a word, it may be said that there was no evidence of the disease being infectious.
In this regard the same mystery surrounds the disease, and the same perplexity exists in the
minds of the profession, as has previously been noted. The question "What is exactly cerebro-spinal
fever ? " is heard as often as before. It cannot be denied that it is a very elusive entity, and the
diagnosis nearly always turns on bacteriological research. Bacteriology apart, there would be very
little cerebro-spinal fever in London at the present time.
It is interesting to analyse shortly the diagnoses of the cases. Of the 123 diagnosed during
life, 59 were not confirmed by subsequent examination. Of the remaining 64 cases in which the final
diagnosis agreed with that made originally, no bacteriological or post-mortem diagnosis was made in 15
cases ; and in another 29 the disease was specified as posterior basal meningitis, a sub-acute disease
allied to cerebro-spinal fever, but commonly regarded as non-infectious. Thus only 20 remain, out of a
total of 123 originally diagnosed, in which the acute form was diagnosed, and confirmed bacteriologically.
But these 20 cases were not diagnosed by the same bacteriologist and therefore may have presented