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15
hand respecting the "trailers," to use Leichtenstern's term. With regard to these, new facts
emerge almost day by day. In the years round about the pandemics prior to that of 1890, attention
had been more especially focussed upon the relationship of certain respiratory diseases to influenza,
though one plain instance, that of the "cold plague" of 1812-14 (Lancet 11th Mar., 1922, p. 512),
remained unrecognised until it was recently unearthed by the Hon. W. R. Riddel!. In the years prior
to 1918, there was intensive study of the nervous diseases associated with influenza. Recent experience
goes to emphasise anew the fact that the gastro-intestinal forms of influenza also merit more careful
consideration than has hitherto been accorded to them; moreover, careful study of "scarlet fever" in
London and elsewhere during the last two years has led to recognition of failure to recognise the influenzal
nature of outbreaks of febrile illness accompanied at one time by sore throat and glandular enlargement,
at another by vomiting or diarrhoea, and yet further occasionally associated in particular instances with
a rash simulating scarlet fever, measles or rötheln; while again in other cases, during the last two or
three years, influenza has mimicked appendicitis or one of the fevers of the typhoid group, particularly
paratyphoid B.
The records of epidemic disease in parts of the world which apparently suffer comparatively
lightly from influenza, for example the sparsely inhabited areas, still need to be much more carefully
explored than has hitherto been found possible: work such as that done by Brorström in rural Sweden
was largely responsible for bringing to light the close association between influenza and poliomyelitis.
Again, influenza in the tropics has been comparatively speaking little studied; it has been
described as "dengue" or as "3 day" or "5 day fever," and has been supposed to be as peculiar to
Durban, or Sierra Leone, or some far Eastern port, as the "sweating sickness" was held to be characteristically
and indeed exclusively "English" in the 15th century. Inter-pandemic periods of years
in tropical regions are for the most part left blank so far as influenzal prevalences are concerned in all the
records; the nervous or other forerunners of influenza, and its trailers, have been lost among prevalences
of typho-malarias, paralytic beri beris, or have otherwise gone astray; again, for examples of gastrointestinal
forms of influenza one would naturally turn to hot countries, but as to any such the records
remain silent. The study, however, of the behaviour of influenza in the large cities of Europe, and of
the United States and Canada, clearly shows that while epidemiology cannot fail to take account of
years in which influenza prevails in pandemic phase, note must also be made of the years shortly preceding
and following the pandemic years, which also bear the impress of the "influence" though in
considerably modified form; and, thereupon, it may be inferred with some show of probability that
at the midpoints between pandemic and pandemic, in the troughs of the pandemic waves, the " influence
" is also there, but is, so to speak, in mufti, exhibiting mainly its immunising effects, and thus
appearing to play a far less important part than it assumes when the population has become susceptible
to influenza in pandemic phase. Much further light upon this question of immunisation would doubtless
be forthcoming, were it only possible to learn something of the behaviour of the influenzal group
of diseases (not omitting reference to some of the so-called dengues and beri beris) in the great aggregations
of populations in British India or in China; or again, if it were possible to examine the influenza
history of some of those remote and barely populated areas, such as Greenland or the Kirghiz Steppes,
which never seem to figure in reports on influenza unless it be as suspected sources of origin for one or
other of the pandemic waves.
It may here appropriately be mentioned that a letter (dated 29th October, 1921), was received
from Dr. Chas. Porter, Medical Officer of Health of Johannesburg, in which he states that following upon
outbreaks in that city, in 1918 and 1919, of encephalo-myelitis with or without lethargic symptoms,
a recrudescence of the condition had occurred during the preceding six weeks. He says, "Complaint
has been of influenza, but instead of symptoms being pulmonary, gastric or in the back or legs they are
cerebral, e.g., headache, diplopia, meningitis, paresis of limbs, mental obfuscation, etc., 40 per cent of the
graver attacks being fatal." He adds, "The illness referred to has been variously diagnosed as influenza
or typhoid or cerebrospinal meningitis. Against the latter diagnosis, however, are the facts
that in nearly every case, examination of the cerebrospinal fluid has been negative and lumbar puncture
and Flexner's serum have proved useless."
In previous reports reference has been made to recent laboratory work on lines which run
parallel with those representing the trend of epidemiological observation regarding the influenzal group
of diseases during the last few years. F. d'Herelle whose work, originally carried out in connection
with dysentery, has aroused considerable interest, has just published a monograph on the subject ("Le
Bacteriophage son rôle dans l'immunite," Paris, 1921. Masson et Cie.). His contention, briefly expressed
is as follows: Bacteriology has hitherto been concerned merely with the " problem of two bodies
—bacterium and cultivating medium—the latter being either the actual host invaded by the bacterium
or the medium in which the germ is cultivated. This problem was already a sufficiently complex
one; far less complex, however, than the "problem of three bodies " with which bacteriologists are
now confronted. In this latter case d'Herelle contends that it is necessary to study the interactions
between first the medium (whether the cultivating medium or the invaded host itself), second the bacterial
parasite, and third the ultra-microscopic bacteriophage which grows at the expense of the bacterial
parasite. These observations have particular interest in connection with recent work on influenza
and the influenzal group of diseases.
The number of cases of cerebrospinal fever and post basic meningitis notified during 1921 was
109 as compared with 164 for the previous year, thus continuing the steady decline which has taken
place in the incidence of the disease in the past five years. Of the 109 cases notified, 20 were not
confirmed as cases of cerebrospinal fever or post basic meningitis; on the other hand 25 cases were
recorded, mainly through the Registrar General's Death Returns, which were not notified under the Act.
The actual number of cases was therefore 114, of which 89 (78 per cent.) proved fatal.
Cerebrospinal
fever.