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9
follow up the transformations p-esented and to measure the instability resulting, as it was presumed,
from inter-action between a germ and its environment.
Further study was made of the subject when the Glasgow and Belfast cerebrospinal fever outbreaks
occurred, in 1906, and when Brorstrom and others at about the same time directed attention to the
influenzal nature of the poliomyelitis outbreaks of Scandinavia. Later, in the annual reports from 1914
onwards, the relation between cerebrospinal fever and influenza in London was studied in detail; and
it transpired in 1916 that similar observations had been made by Lt.-Col. Dorgan in army camps. Thus,
already; prior to 1918, it was apparent, as was stated in the report for 1917 published last year, that
London was once again being subjected to an epidemic influence eminently protean in its behaviour,
and then at length (in June and July, 1918) the "posting character" of declared pandemic influenza
became clearly manifested; incidentally, as Was then observed, "the close connection between polioencephalitis
(including of course encephalitis lethargica), poliomyelitis, cerebrospinal meningitis and
influenza now seemed to be established." Similar lines of enquiry have been followed by Dr. F. G.
Crookshank in his Chadwick lectures and in his writings on Epidemic Encephalitis. In the special report
on influenza, which is appended, the attempt is made to show that the theory above outlined derives
further support from studv of earlier writings on the historv of epidemics.
Cerebrospinal
fever
lhere was a marked diminution in the prevalence of cerebrospinal fever during 1918, only 265 (
cases having been notified, as compared with 430, 432 and 674 cases in 1917, 1916 and 1915 respectively.8
Of the 265 cases, 31 proved ultimately not to be cerebrospinal fever.

In 202 cases forms containing detailed information Were received from borough medical officers
and were circulated in accordance with the usual practice.
The services of the Council's expert medical staff were requisitioned on 70 occasions, either for
visiting suspected cases and making lumbar punctures, or for examining specimens of cerebrospinal fluid
or other material. Of these 22 were actual visits to the homes of the patients and in these cases 10 lumbar
punctures were performed; only 4 proved to be cases of cerebrospinal fever, the remainder being influenza
(1), tubercular meningitis (3) and poliomyelitis (2). The 12 remaining cases included cerebrospinal
fever (1), chronic post basic meningitis (1), poliomyelitis (1), febricula (2), toxaemia resulting from
pyorrhoea (1), cerebral abscess (1), influenza (3), pneumonia (1), and erythema simplex (1).
In addition to these visits 48 specimens of fluid or other material were received for bacteriological
examination, mainly from infirmaries. Of these seven contained meningococci, 15 were shown to
be tubercular meningitis and the remainder proved to be encephalitis (7), meningismus (7), pneumococcal
meningitis (2), septic meningitis (1), cerebral abscess (1), influenza (1); whilst in seven cases there was
neither evidence of meningitis nor any indication to assist in a diagnosis; one specimen proved to be
contaminated and no result could be obtained.
During the year 77 persons in contact with cerebrospinal fever were examined, of whom four were
found to be carrying the meningococcus, and were kept under observation. In each case, however, a
negative result was obtained on a second examination about a fortnight later.
Under the Public Health (Cerebro-Spinal Fever) Regulations, 1918, issued by the Local Government
Board on the 1st April, 1918, the Council of any Administrative County or of any County Borough is
empowered to provide or arrange (1) for the provision of serum for the treatment of cases or suspected
cases of cerebrospinal fever occurring among the inhabitants of the County or Borough, together with
the necessary apparatus for the use of the serum, and (2) for the examination of any person who is
suspected to be suffering from the disease. With reference to (2) the Council had already in 1915 made
the necessary arrangements. As regards (1) provision had been made in London for the supply of antimeningococcal
serum in the hospitals of the Metropolitan Asylums Board, the general hospitals, infirmaries,
etc. The requirement of the regulations, as far as London was concerned, is therefore limited to those
cases which are treated at home. In this connection the Council agreed on 30th July, 1918, to provide
serum for the treatment of cases of cerebrospinal fever seen in consultation with the Council's medical
staff, and arrangements have been made wherebv a supply of serum will be available in such cases.
Encephalitis
lethargies
Detailed particulars w ere obtained concerning 78 cases wh ch came under the observation of the
Council s medical staff, but of these only 49 presented the characteristic group of symptoms ; the
remainder were found on examination to be due to tubercular meningitis, cerebrospinal meningitis, or
to various other c> iditions. With regard to the general symptomatology of these 49 cases, it may be
said that the onset of illness Was characterised by lethargy, accompanied by high temperature and
* Not including cases in which the diagnosis was withdrawn.
60129 B