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8
The change
of view
brought
about by
study of
bacteriology
In his further report, published in 1893 he has a note on "clinical features of the later epidemics,"
in which he specially refers to the "greater tendency to lung complications" and to "profound disturbance
of nutrition of the nervous system," and he adds, "some practitioners in the eastern counties
have observed influenza to have been accompanied or followed in the later epidemics by symptoms
resembling those of cerebro-spinal meningitis." He also quotes Dr. Bezley Thome to the effect that
" influenza essentially consists of symptoms caused by toxic influences exerted upon the cerebro-spinal
meninges." It may be added that Graves believed " the poison which produced influenza acted on the
nervous system in general," and he quotes Dr. Peyton Blakiston's statement that "influenza is an affection
of the nervous system." The position taken up by Dr. Parsons was the result of the experience of
the pandemic of 1890-92 studied in the light of the epidemiological teaching current at that time.
But then came a change of outlook associated with the rapid development of the study of,
bacteriology. Quite at the outset a "causal germ," Pfeiffer's bacillus, was invoked as producing the
at that time, common type of influenza; then at a later date the part played by other germs was considered,
and at length, in 1887, the meningococcus of Weiehselbaum was identified and declared to be
' the causal organism of cerebro-sninal fever.
The easy descent was already in full progress at the close of the century. Thus, in Dr. Bruce
Low's paper on Epidemic Cerebro-spinal Meningitis, of 1889, reference is made to the fact that this
disease and influenza not infrequently concur and that the one may be mistaken for the other, and
then follows this striking passage : " Some authorities, indeed, have advanceel the view that these two
diseases are one and the same. But it is now generally admitted that epidemic influenza is associated
with a special organism, the bacillus of Pfeiffcr, and as will shortly be seen, cerebro-spinal fever is now
known to be associated with a special diplococcus. So that to the bacteriologist in future we shall have
to look to settle the diagnosis in doubtful cases." The outcome • of this sale of the birthright of
epidemiology has been serious enough, and the trouble would never have arisen if more attention had
been paid to the epidemiological teaching.
Sydenham wrote in the second chapter (On Epidemic Diseases) of his Medical Observations
" Nothing, in my opinion, strikes the mind that contemplates the whole and open domain of medicine
with greater wonder than the well-known varied anel inconsistent character of those diseases which we
call epidemic. It is not so much that they reflect and depend upon different conditions of climate in
one and the same year as that they represent different and dissimilar constitutions of different and
dissimilar years." The contrast with the modern point of view may be illustrated by comparing
Sydenham's description of the new fever of 1685 with the bacteriological study of the epidemic visitation
of 1915. Account is given of the former in Sydenham's "Schedula Monitoria" and the description
closely tallies (see Proc. Roy. Soc. Med. Vol. 8) with that of the epidemic which prevailed in London
three years ago. Sydenham states that his epidemic "commenced in February and the patient often
had chills and flushes by turns and frequently complained of pain in his head and joints and generally
had a cough. There was pain also in the neck and fauces, the fever was continued, and the patient
might determine the. fever to the brain and convert it to a frenzy " ; petechia? and purple blotches,
perspirations and peripneumonies are all referred to, and it is added that "of all the fevers this attacked
the brain most and could not bo detached from it without great trouble and danger." All this repeated
itself in February 1915, but the bacteriologists could not see the wood bccause of the trees and hencc
roferrcd each particular symptom complex as it presented itself to its supposed appropriate "causal
organism." It was impossible therefore to avoid surmising that Sydenham, if he were back here
among us, would laugh when he was told that the influenza-like cases of the 1915 outbreak were due to
Pfeiffer's bacillus and the sore throats were due to the micrococcus catarrhalis, and certain other conditions
were due to pneumococci and streptococci and others to meningococci and yet others to parameningococci.
He would surely eleclare that the germs which the bacteriologists were demonstrating
were nothing more than " associated organisms " or " sccondary invaders."
The relation
between
cases of
cerebrospinal
fever and
poliomyolit:s
and the
so-called
abortive
cases, many
of which are
described as
cases of
influenza.
In London, cerebrospinal fever was first made notifiable in 1907 and poliomyelitis in 1911. Study
has been made of the confusion which has arisen between epidemics of cerebrospinal fever and influenza
for over twelve years, attention being first called to it by the occurrence of "an epidemic simulating
influenza " in East Herts in the winter of 1904-05. This was described as a " new disease," and influenza
throughout the entire history has, of course, been commonly designated by that name. In 1906-07
an " outbreak simulating influenza " occurred in an institution in Holborn. At that time it seemed
obvious that the cases which were being described as cerebrospinal fever in Glasgow and Belfast had
at any rate some counterpart in the influenzas then prevailing in London. It was also then quite clear
that, as Dr. Parsons had already pointed out in 1891, different forms of influenza might occur under
the same roof and were evidently mere varieties of the same disease. Two or three years after this
Dr. Brorstrom's report upon epidemic poliomyelitis in Sweden was published. In this volume, " Akute
Kinderlahmung und Influenza," Leipzig, 1910, the epidemiological relationship of the cases of poliomyelitis
and of influenza was plainly demonstrated. But the same question had already been seen to
arise in London with regard to cerebrospinal meningitis and influenza, and, furthermore, the differentiation
between poliomyelitis anel cerebrospinal fever, though a simple enough task, bacteriologically
speaking, was found by clinicians and epidemiologists when the relation of case to case came to be stuelieel
to present great difficulties. In point of fact, in the light of the classification into varieties of poliomyelitis
acuta formulated by Wickman, a classification accepted by later authorities, the supposed clear
signs of distinction between poliomyelitis and cerebrospinal meningitis, from the epidemiological point
of view, disappear. The difficulty of diagnosis was being experienced, it was found, not only in London,
but throughout the country, by inspectors of the. Local Government Board, and in order temporarily
to meet the official requirements of the case it was arranged that in London all reports relating to