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APPENDIX II.
CEREBROSPINAL FEVER IN LONDON DURING 1908.
Happily there is little to record about this disease. There has been nothing approaching
epidemic prevalence, and, among the reported cases, no evidence of infectiousness. The number
of cases certified has been 85. Inquiries have been made into these by the respective city or borough
medical officer of health, and 72 of the cases have been followed up by myself. The home of each
patient has been visited, and particular attention has been paid to the question of how the disease
might have been conveyed. The friends have been cross-examined as to possible channels of infection,
and as to whether any other case of disease, of any kind, is known to have occurred in
association, such as influenza, whooping cough, or phthisis. Inquiry has also been made into the
duration of residence of the patient in the locality, whether, if an infant, he has been breast fed or
not, whether pet animals have been kept, and whether there is any cause for the illness which gossip
or information can suggest. In many cases the local medical attendants have been interviewed or
written to, as well as the hospital staff who were in attendance on the case. In no single instance
could any connection be traced between two cases : no case appears to have led up to any other, or
to be derived from any other ; no condition has been found to exist in any two or more cases which
could be regarded as a common factor of causation.
With the object of eliciting any possible infectious factor, inquiry was made into certified
cases, whether they were subsequently verified or not. The same difficulty in verification was experienced
as in dealing with the cases which occurred during the year 1907. In the notes on
those cases is recorded the conflict of evidence which may arise between the pathologist and the
bacteriologist, and the following cases which occurred during 1908 bear on the same subject.
T. F. R., aged 9 months, had an illness of 14 days duration with cerebral symptoms and fatal termination
; post mortem, the meninges contained purulent looking fluid ; at the tip of each temporomaxillary
lobe of the brain was a little creamy pus; there was thrombosis of vessels on the vertex,
and an excess of fluid in the lateral ventricles ; the cord appeared to be normal to the naked eye ;
the left middle ear contained some pus, but the drum was not perforated nor could any opening be
found from the ear into the inside of the cranium, or any evidence of carious bone. Such is the
post-mortem report of the naked eye conditions found. At once the question suggests itself as to
whether the meningitis may not have been secondary to the pus in the left middle ear. But this
reading of the case is considered to be negatived by the bacteriological report which states that the
Diplococcus intracellular is meningitidis of Weichselbaum was found in the cerebrospinal fluid during
life, and also after death in the fluid of the lateral ventricles. On this evidence, the case is classed
as one of a specific infectious disease. Of a similar nature was the case T. S. I., 1 year old, who
died after an illness of about 10 weeks with cerebral symptoms, and was found post-mortem to
have purulent meningitis at the posterior base, and to have pus in both middle ears. In the
cerebrospinal fluid the meningococcus was found. No doubt it may be held that in this case the
pus in the middle ears was secondary to that in the meninges, and that in the first case the middle
ear pus was merely that often found there in young children apparently otherwise healthy. No
bacteriological examination appears to have been made of the aural pus in either of these cases. Itwould
have been interesting if this had been done; and further, if it could be ascertained in what proportion
of cerebrospinal fever cases there is any collection of pus in the middle ear ; at present this
organ is one which is not always examined post-mortem, or, if examined, its condition is not recorded.
No excuse is needed for dwelling on the bacteriological method of identification of the disease,
for that is the basis upon which its diagnosis ultimately rests. Bacteriology is considered capable of
supplying an infallible test of its authenticity, but it is doubtful if this claim will always stand
examination. In order to see plainly what the claim is, the report of Dr. Mervyn Gordon to the
Medical Officer of the Local Government Board (February, 1907), may again be quoted.
"Although this country has hitherto been remarkably free from epidemics of cerebrospinal
meningitis, the disease obtains here sporadically ; and this circumstance, coupled with
the fact that epidemics of cerebrospinal meningitis have recently prevailed abroad, renders
information concerning the characters of the special micrococcus associated with its product
tion particularly desirable. Moreover, the presence within the human body of this microorganism
has been found to constitute the surest test whereby cases of epidemic cerebrospinal
meningitis can be detected. Its identification, therefore, becomes a matter of no little importance
with reference to that early and accurate recognition of this disease upon which a successful
system of prevention of the malady must in our present state of knowledge in great
part, if not wholly, depend."—(Report of Dr. Mervyn Gordon to the Medical Officer of the
Local Government Board, February, 1907.)
Dr. Gordon reviews the discovery and general recognition of the organism concerned, viz.:
the Diplococcus intracellular is meningitidis of Weichselbaum; and says, "At the present day, therefore,
it is generally admitted that the Diplococcus intracellular is of Weichselbaum, or as this microorganism
is sometimes termed Micrococcus meningitidis cerebrospinalis, or more briefly the meningococcus,
is certainly the chief, and apparently the sole, bacteriological factor in epidemic cerebrospinal
meningitis." The identification of the meningococcus, he proceeds to say, is not a simple matter.
There are numerous other micro-organisms which resemble it. Special methods and great care are
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