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APPENDIX. I.
Report by Dr. Wanklyn on Cerebro-Spinal Fever in London in 1007.
Advantage has been taken of the present notification period of cerebro-spinal fever to consider
certain aspects of the disease which seem specially worthy of study. These are its identity, and the
methods of its identification. The following notes, based on recent experience in London, deal
especially with the uncertainty surrounding this disease, and with the value to be attached to the
various kinds of evidence on which its diagnosis is based. The conclusion is reached that further
inquiry is needed to place our knowledge upon a satisfactory footing.
In London recently there has been nothing in the nature of an epidemic, and this should
be borne in mind in reading what follows, for zymotic diseases have a tendency to behave differently
in epidemic and non-epidemic times. Moreover, in non-epidemic times, actual cases of the
malady are more apt to be obscured by cases of other maladies presenting like symptoms. The various
sporadic cases, however, as they arose, have been enquired into, and certain of them have been
investigated in closer detail. In these cases besides visits to patients in hospital, and to their
homes to see the relatives, visits have also been paid to the various medical men in attendance
on each case, and as full details as possible have been obtained from them by interviews and
correspondence. Though the results are less complete than it was hoped they would be, mainly
owing to the complete details of many cases being unobtainable, yet they seemed worthy of record,
if only to point the way in future enquiries. In presenting what follows I have endeavoured to
avoid any controversial spirit. My sole object has been to let the facts speak for themselves,
and to be guided by them ; so as, if possible, to add to our understanding of a disease as to
which our want of precise knowledge is widely felt.
In the 132 cases notified during the year 1907 the evidence of infection amounts to nil.
There has been, so far as I am aware, no instance of two or more cases being associated, no case in
which infection has been traced to one patient from another ; no group of cases in which there has been
an ascertainable common cause, and no case in which the illness appears to have been transmitted by
any particular factor outside the patient. Among the cases into which I personally enquired at
the patient's homes, 63 in number, there were relatively few instances of associated illness.
"Common colds" have not occurred more frequently among the patient's friends than would have
been expected in any other similar number of the community. W hooping cough I found to be not an
uncommon coincidence, whether more than a mere coincidence I cannot say. A history of sore throats
in nearly every member of the family was given in another case, and was associated with defective
drainage. I was impressed in the case of more than one family of children whom I interviewed with the
dirty, sore, and " running " condition of the mucous orifices, viz., ears, nose or mouth. As will be seen
below (p. 5), in one case, T.T.S., such a condition appeared to be the origin of the illness. Apart from
these points I cannot say that the patients1 homes or surroundings presented any remarkable feature ;
most of the cases came from working-class families, of which some, but by no means all, were very poor.
The point which seemed to me to be of most importance, and worthy of special attention in future
enquiry, was the condition of the mucous membranes of the ears, and also of the nose, mouth and throat,
both of the patient, and of the children who may have been in contact with him.
The problem which constantly presents itself to an enquirer into cerebro-spinal fever, and
is impossible to get away from, is the identity of the disease, and its diagnosis. Judging from my
experience the difficulty appears to be one which exercises the minds of the majority of the profession
in London who are brought in contact with the disease, namely, to say what does, in point of fact, constitute
cerebro-spinal fever. It may be illustrated by the nature of letters replying to inquiries about
cases. In the returns of deaths from meningitis, some of the deaths are certified to have been caused
by definite morbid processes, such as cerebral abscess. But many, especially among infants, are certified
in such terms as " meningitis," or "simple meningitis," or "meningitis and coma," or "meningitis
and convulsions." In a number of such cases enquiries were made by letter from the certifying
physician whether there was any reason for suspecting the case to have been one of epidemic cerebrospinal
meningitis. Replies took some such form as this: "The case was one of acute meningitis and
not epidemic cerebro-spinal meningitis," or "it was a case of simple and not of cerebro-spinal meningitis."
What was the precise distinction in the mind of the writers between these various forms of disease
is not easy to say. In conversation the same thing was equally remarkable. Over and over again the
question was asked: "What exactly is cerebro-spinal fever?" "And how am I to know it when
I see it ? "
What a remarkable fact this uncertainty is, seems hardly to be appreciated at its full import.
That mystery should still surround a disease, epidemics of which have been recorded and studied
for the past hundred years, and still continue to occur, seems at first sight very surprising It might
have been thought that a specific disorder, so far from uncommon as this is, would have been clearly
understood and recognisable by now. But with many physicians the reverse appears to be the case.
The principal reason for this appears to be one of nomenclature. No definition seems to be in
current general use which will readily enable cases to be placed within or without the class termed
cerebro-spinal fever." It seems almost impossible to make any real advance in knowledge until
there is a common understanding as to what to include in the term.
It was to assist in arriving at this result that the Public Health Committee in May, 1907,
approached the President of the Royal College of Physicians, and invited his opinion as to whether
cerebro-spinal fever (epidemic cerebro-spinal meningitis) should include, for notification, posterior