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34
Annual Report of the London County Council, 1914.
proved to be measles, one was urticaria, one had influenza, whilst one case was diagnosed and notified as
scarlet fever. In three instances no fluid could be obtained by means of lumbar puncture; one of these
was found to be a case of tuberculous meningitis,one was notified as diphtheria and the otherwas certified
as a case of acute meningitis. On six occasions specimens of material for bacteriological examinatiou
have been forwarded to the Council's Public Health Laboratory, two of them being obtained postmortem;
meningococci were discovered in four of these cases, including the post-mortem cases, and
the other two gave negative results. In three instances cultures were made on account of the presenile
of suspicious pharyngeal symptoms or other suspicious signs unaccompanied by any indications of
meningitis, one of the patients being a soldier. Bacteriological examination of the specimens on all
three occasions gave a negative result.
Out of a large number of persons who had been in contact with cases of cerebro-spinal fever during
the period under review, 329 persons were selected for bacteriological examination by reason of their
having been closely associated with the patients. Of the total number of persons examined, 31 (10 per
cent.) proved to be carriers of the meningococcus.
An attempt has been made to ascertain whether any correlation exists between closeness of
association and the presence or absence of the meningococcus among the contacts examined. The
enquiry was conducted on the lines of classifying the contacts according to their degree of relationship
to the patient. It was thought that this method might show significant differences in the proportion of
carriers found in the various groups classified. Thus, in the case of young children attacked by the disease
it might be assumed that mothers of these children come into closer association with them than the
father, and older sisters than older brothers, and so on. No satisfactory conclusion on the point in question
could however be obtained from the figures, which gave inconsistent results. The value of the
results was to some extent vitiated by the fact that the contacts examined formed a selected class
and included only those persons who had been in intimate contact with the patient, and further than
this it is apparent when the contacts selected for examination are classified into groups that the numbers
forming the groups are much too small from a statistical point of view to determine the question at
issue. In the majority of cases the carriers were re-examined at varying intervals of two to'six weeks,
but only on four occasions were positive results obtained on a second examination, and only in one on
a third examination. Of these three were kept under observation.
In summary of the conclusions arrived at as the result of the inquiries made it may be stated
that there was no evidence that any of the carriers, discovered during the course of these investigations,
had been responsible for giving rise to cases of cerebro-spinal meningitis, although they retained
complete freedom of action. The advice usually given in such cases was to live as much as possible in
the fresh air, to avoid close unnecessary contact with other persons, and to use throat gargles and nasal
douches. Of the contacts examined, none of the persons found to be carrying the meningococcus
showed, at any time, any symptoms of a serious character. The scope of the present inquiry has been
somewhat limited, and it would be unwarrantable to draw definite conclusions with regard to influence
of " carrier " cases on the spread of cerebro-spinal meningitis without further investigations.
Inquiries are still being pursued, but this short resume of the work already done clearly indicates
that the facilities for obtaining expert advice have been freely utilised and appreciated.
Influenza and cerebrospinal fever.
The prevalences of these diseases, which commenced in London at the end of 1914, have afforded
further opportunity for study of their inter-relationship. The large amount of attention which has
recently been devoted to their bacteriology has dwarfed almost to insignificance the measure of consideration
which has been allotted to their epidemiology, and this fact is the more regrettable because
the problem of their epidemiological relationship is an old standing one and presses for further investigation.
Already in the fifteenth and sixteenth centuries there were records showing that outbreaks of
what was then called" sweating sickness "(doubtless the modern "influenza") were apt to occur
concurrently with prevalences of diseases described as "hauptkrankheit," "encephalitis," and "febrile
cerebritis." (See The Milroy Lectures, 1906). Symes Thompson in his "Influenza, an historical survey "
makes several references to cerebral symptoms in cases of influenza outbreaks. Ozanam in his "Histoire
des maladies epidemiques "has a chapter on Encephalite, or Fievre cerebrale, which is full of interest
in the same connection; he says, for example, speaking of this brain fever, "File se combina en 1557 et
1559 avec l'epidemie catarrhale qui parcourut successivement l'Allemagne, la Hollande, la France, et
1'Espagne; elle fut mortelle pour les enfants"... and, again, he says, "La cephalee se combina encore
en 1580 avec l'epidemie catarrhale qui parcourut toute l'Europe"... then he mentions an Army
outbreak in 1616 . . . further he refers to a particularly noteworthy outbreak described by Saalmann
in Westphalia, in 1788, in which rigidity of the limbs, "eruption pourpree" and "inflammation des
meninges et du cerveau" are mentioned. Finally various authors in the nineteenth century have
described varieties of influenza in which the nervous system was principally affected.
Attention was specially directed to this question in London at the time of the occurence of "An
epidemic influenza " in East Herts, in the winter of 1904—5; the outbreak was carefully studied by
Drs. R. A. Dunn and M. H. Gordon, and the claim that, epidemiologically considered, the outbreak
was one of influenza was made by Dr. Lovell Drage and myself at the time (see The Milroy Lectures,
1906, p, 39). In 1906, cerebro-spinal fever was reported in Belfast and in Glasgow and as a consequence
the disease was made notifiable in London. In that year an anomalous "Outbreak simulating influenza"
occurred in an institution in Holborn, and was reported upon by Dr. Bond (Trans. Epid. Soc. of London,
1906-7). In a contribution supplied to the discussion on Dr. Bond's paper I ventured the suggestion
that in some of the outbreaks which had been described by medical inspectors of the Local Government