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A NOTE ON THE PRESENCE OF ANTIBODIES TO HERPES VIRUS
857
performed, and the remaining adductors and ham- from post-encephalitic patients for antibodies to strings on both sides were stretched. These measures herpes. If herpes virus were the causal agent of effectively corrected the " crossed-leg" deformity, encephalitis lethargica, antibodies might be expected but some contraction of the hamstrings persisted. to be present in view of the following considerations. Within a fortnight, however, he was able to lift First, many neurologists believe that post-encephalitic both legs off the bed and move them at all joints. parkinsonism is a manifestation of a chronic infection He had now, also, complete control over the bladder. with the agent of encephalitis and not a mere residuum Progress in walking continued slowly but was con- due to destruction of nervous tissue. Secondly, .siderably hampered by increasing contracture of rabbits infected with herpes, including those suffering the hamstring muscles, preventing him from from a chronic form of encephalitis, possess neutralisstraightening his legs. Consequently, some eight ing antibodies in their serum. Flexner3 reported in months later, further orthopaedic treatment was 1923 that convalescent epidemic encephalitis serum undertaken. Tenotomy of the hamstrings on both was somewhat more protective against herpes virus sides was performed and the legs were put up in in rabbits than were a few samples of normal human plaster, fully extended, for three weeks. At the end serum. Since our investigation was begun Zinsser of this period he commenced walking again, was and Tang 4 have published the results of a study on able to stand erect, and soon was getting about with the same lines. They found that 39 of 45 postmuch less fatigue and more comfort. The bowels encephalitics (86-7 per cent.) had antibodies to and bladder were acting normally. When last seen herpes in their serum, while only 11 out of 17 adult 15 months after the removal of the controls (64-7 per cent.) showed antibodies. Normal -some tumour-he looked and felt very well indeed. He children gave an even lower percentage of positive Zinsser and Tang were was able to walk erect and quite smartly but with results (43-4 per cent.). knees. He had no naturally reluctant to draw conclusions from these just a suggestionorof stiffness at the tingling, pains, spontaneous flexor spasms in his figures. They tested for anti-herpes properties in legs and no tightness around the body. He had sera by incubating the serum to be tested with 2 to
control over his sphincters but constipation rather troublesome. While the legs showed spasticity in extension, he could flex and extend them easily at all joints. The knee-jerks were exaggerated and equal, and ankle-clonus was present on both sides. The plantar responses were slightly extensor. Sensory recovery was marked. Sensibility to pinprick had completely recovered. Thermal sensibility also was normal, except for a zone of slight diminution encircling the body from the level of the nipples to that of the ensiform cartilage. Sensibility to the brush was still diminished, but only slightly so, in the legs and trunk up to about the seventh dorsal spine Vibration sense behind and the nipples in front. was still slightly diminished from the knees downwards, a little more so in the right leg than in the left.
complete was
Clinical and
Laboratory Notes.
4 minimal lethal doses of virus and inoculating rabbits intracerebrally. This method, though it apparently gave consistent results, is expensive in animals and allows very little margin for possible variation in the susceptibility of the rabbits. Our investigations were undertaken because we had at hand a simple method of testing for antibodies to herpes. We found, as Gay and Holden3 and Wilson Smithhave done, that some strains of herpes give very satisfactory lesions when inoculated intradermally into rabbits, and that with such a technique sharp neutralisation of virus by immune serum can be shown. We used a strain (E.L.i) kindly given to us by Dr. J. R. Perdrau ; this at first gave unsatisfactory intradermal lesions, but after a few passages in tissue cultures was very satisfactory fcr our purposes. The virus multiplied readily in cultures of rabbit testis in dilute rabbit serum, as lately described by one of us (Andrewes7). Fluid from tissue culture was mixed with an equal volume of immune serum, and after a few minutes’ contact at room temperature, 0-1 c.cm., was inoculated
intradermally. A NOTE
ON THE
Results. Human sera were found to fall sharply into two groups. Either they did not influence at all the size of the lesion produced by the virus, or they IN POST-ENCEPHALITIC AND OTHER HUMAN SERA. neutralised a thousand infective doses completely. It will be seen from Table I. that 21 out of 28 (or BY C. H. ANDREWES, M.D., M.R.C.P. LOND., 75 per cent.) control sera contained antibodies to MEMBER OF SCIENTIFIC STAFF, NATIONAL INSTITUTE FOR MEDICAL herpes ; such antibodies were less evident in the RESEARCH; few sera examined from normal persons, chiefly AND medical students, than in sera of assorted hospital patients, but the possible significance of this difference E. ARNOLD CARMICHAEL, M.B., M.R.C.P. LOND., has not been further studied. In Table II. are set CHIEF ASSISTANT, PROFESSORIAL MEDICAL UNIT, forth the results of testing the sera of 25 postST. BARTHOLOMEW’S HOSPITAL. encephalitic patients ; brief details are given of the history of their disease. Antibodies were found in Two main theories concerning the setiology of the serum of 18 out of 25 patients (or 72 per cent.), - encephalitis lethargica are current. Some hold that approximately the same percentage as in the control the disease is caused by the virus of herpes simplex, group. which under exceptional circumstances becomes All the patients whose serum was tested were whether or not they had ever suffered from neurotropic in man. This view is based on the asked occasional recovery of herpes virus from the brains " herpes simplex," the nature of which was described of patients dead of encephalitis lethargica and on to them. Very few replied in the affirmative, but it the fact that herpes virus can produce not only an is not felt that much reliance can be placed upon the acute or chronic encephalitis in rabbits, but also, answers obtained. In addition to the unselected as Zinsser has shown, a chronic encephalitis in group of normals in Table II., sera were examined certain monkeys which is not unlike encephalitis from seven subjects, all workers at the National lethargica in man. Others, however, are unconvinced Institute for Medical Research and all liable to by this evidence and maintain that the cause of frequently recurring attacks of labial herpes. Antiencephalitis lethargica is an unknown specific neuro- bodies were present in all seven of these sera. It tropic virus. (See Zinsser’s2 recent review of the is of particular interest that one of them had had an attack of herpes six days before he was bled, problem.) It seemed that some light might be thrown on the while another had an attack four days after blood was aetiology of encephalitis lethargica by examining sera taken. Herpes simplex is one of the few known virus
PRESENCE
OF
ANTIBODIES TO VIRUS
HERPES
858 One of us (E. A. C.) is responsible for the clinical diagnosis of the patients and for obtaining the sera; the other (0. H. A.) for the animal tests. We thank Prof. F. Fraser for permission to utilise the material under his care and Prof. Major Greenwood for kindly examining the available figures. He assures us that statistically there is no significant difference between the post-encephalitic and control sera either in our 4
diseases which does not lead to lasting immunity at least in man. It appears from these observations that in some obscure way herpes can recur in man despite the presence of antibodies in the serum. TABLE I.-Antibodies to
Herpes in Control Sera.
series
or
in that of Zinsser and
Tang.4
References. 1. Zinsser, H. : Jour. Exp. Med., 1929, xlix., 661. 2. : Archives of Pathology, 1928, vi., 271. ,, 3. Flexner, S. : Jour. Amer. Med. Assoc., 1923, lxxxi., 1785. 4. Zinsser, and Tang, F. F. : Jour. Immunol., 1929, xvii., 343. 5. Gay, F., and Holden, M. : Jour. Inf. Dis., 1929, xlv., 415. 6. Smith, Wilson: Jour. Path. and Bact., 1930, xxxiii., 273. 7. Andrewes, C. H. : Ibid., 1930, xxxiii., 301.
AN IMPROVED METHOD OF LIGATURING THE EXTERNAL CAROTID ARTERY. BY NORMAN PATTERSON, M.B., CH.B. EDIN.,
F.R.C.S. ENG., NOSE AND EAR LONDON HOSPITAL.
SURGEON, THROAT,
*
Medical student.
Ad. = Adult.
There
was no
herpes simplex in any patient except Case 22 and history in Case 19.
IT occurred to me some time ago that the operation of ligature of the external carotid might be simplified. I have on two occasions carried out a modified procedure which I am convinced possesses definite advantages over the classical method. The preliminary stages of the operation are the same as those described in the text-books. The carotid sheath is exposed and
history of a
DEPARTMENT,
doubtful
TABLE II.-Antibodies to Herpes in Postencephalitic S’era.
incisect
over
zne
internal jjugularr vein, which is freed from
its
fascial
covering for a length of from 2 to 3 inches in the
neighbourhood responding to
cor-
the
region of the carotid bifurcation. vein is now
The
carefully separated underlying structures, including the vagus nerve.
from
It is then retracted towards the mesial plane, instead of laterally as in the classical operation, until the bifurcation of the common carotid comes into view. The hyponerve tends to be retracted forwards with the vein and may never come into sight ; of course, care must be taken to avoid damaging this nerve or its branch, the descendens hypoglossi. The actual ligation of the I external carotid is carried out at the site of election by adopting the same technique as in the classical procedure. Sometimes it may be advisable to tie the ascending pharyngeal artery. In uncomplicated cases this method is simpler than the older one.
glossal
Parkinsonism was present in all the cases. There was a doubtful history of herpes simplex in Cases 35 and 38, but no history in any other patient.
Yet that serum can prevent the virus from infecting rabbit’s skin or a tissue culture of rabbits’ testis.
a
Summary. Antibodies to herpes virus
were found in the serum of 72 per cent. of 25 patients with post-encephalitic parkinsonism and in 75 per cent. of 28 unselected controls. These observations, therefore, lend no support to the view that the virus of herpes simplex is the essential cause of encephalitis lethargica. Seven subjects with frequently recurring labial herpes all had antibodies in their sera ; the significance of this is discussed.
I
Difficulty of the Recognised Route. operation by the recognised route may be extremely difficult, where there is a regular plexus of large veins over the bifurcation of the carotid and more especially if in addition there are enlarged glands, the seat of acute or chronic inflammation, possibly associated with adhesions. The veins which The
performed, and the remaining adductors and ham- from post-encephalitic patients for antibodies to strings on both sides were stretched. These measures herpes. If herpes virus were the causal agent of effectively corrected the " crossed-leg" deformity, encephalitis lethargica, antibodies might be expected but some contraction of the hamstrings persisted. to be present in view of the following considerations. Within a fortnight, however, he was able to lift First, many neurologists believe that post-encephalitic both legs off the bed and move them at all joints. parkinsonism is a manifestation of a chronic infection He had now, also, complete control over the bladder. with the agent of encephalitis and not a mere residuum Progress in walking continued slowly but was con- due to destruction of nervous tissue. Secondly, .siderably hampered by increasing contracture of rabbits infected with herpes, including those suffering the hamstring muscles, preventing him from from a chronic form of encephalitis, possess neutralisstraightening his legs. Consequently, some eight ing antibodies in their serum. Flexner3 reported in months later, further orthopaedic treatment was 1923 that convalescent epidemic encephalitis serum undertaken. Tenotomy of the hamstrings on both was somewhat more protective against herpes virus sides was performed and the legs were put up in in rabbits than were a few samples of normal human plaster, fully extended, for three weeks. At the end serum. Since our investigation was begun Zinsser of this period he commenced walking again, was and Tang 4 have published the results of a study on able to stand erect, and soon was getting about with the same lines. They found that 39 of 45 postmuch less fatigue and more comfort. The bowels encephalitics (86-7 per cent.) had antibodies to and bladder were acting normally. When last seen herpes in their serum, while only 11 out of 17 adult 15 months after the removal of the controls (64-7 per cent.) showed antibodies. Normal -some tumour-he looked and felt very well indeed. He children gave an even lower percentage of positive Zinsser and Tang were was able to walk erect and quite smartly but with results (43-4 per cent.). knees. He had no naturally reluctant to draw conclusions from these just a suggestionorof stiffness at the tingling, pains, spontaneous flexor spasms in his figures. They tested for anti-herpes properties in legs and no tightness around the body. He had sera by incubating the serum to be tested with 2 to
control over his sphincters but constipation rather troublesome. While the legs showed spasticity in extension, he could flex and extend them easily at all joints. The knee-jerks were exaggerated and equal, and ankle-clonus was present on both sides. The plantar responses were slightly extensor. Sensory recovery was marked. Sensibility to pinprick had completely recovered. Thermal sensibility also was normal, except for a zone of slight diminution encircling the body from the level of the nipples to that of the ensiform cartilage. Sensibility to the brush was still diminished, but only slightly so, in the legs and trunk up to about the seventh dorsal spine Vibration sense behind and the nipples in front. was still slightly diminished from the knees downwards, a little more so in the right leg than in the left.
complete was
Clinical and
Laboratory Notes.
4 minimal lethal doses of virus and inoculating rabbits intracerebrally. This method, though it apparently gave consistent results, is expensive in animals and allows very little margin for possible variation in the susceptibility of the rabbits. Our investigations were undertaken because we had at hand a simple method of testing for antibodies to herpes. We found, as Gay and Holden3 and Wilson Smithhave done, that some strains of herpes give very satisfactory lesions when inoculated intradermally into rabbits, and that with such a technique sharp neutralisation of virus by immune serum can be shown. We used a strain (E.L.i) kindly given to us by Dr. J. R. Perdrau ; this at first gave unsatisfactory intradermal lesions, but after a few passages in tissue cultures was very satisfactory fcr our purposes. The virus multiplied readily in cultures of rabbit testis in dilute rabbit serum, as lately described by one of us (Andrewes7). Fluid from tissue culture was mixed with an equal volume of immune serum, and after a few minutes’ contact at room temperature, 0-1 c.cm., was inoculated
intradermally. A NOTE
ON THE
Results. Human sera were found to fall sharply into two groups. Either they did not influence at all the size of the lesion produced by the virus, or they IN POST-ENCEPHALITIC AND OTHER HUMAN SERA. neutralised a thousand infective doses completely. It will be seen from Table I. that 21 out of 28 (or BY C. H. ANDREWES, M.D., M.R.C.P. LOND., 75 per cent.) control sera contained antibodies to MEMBER OF SCIENTIFIC STAFF, NATIONAL INSTITUTE FOR MEDICAL herpes ; such antibodies were less evident in the RESEARCH; few sera examined from normal persons, chiefly AND medical students, than in sera of assorted hospital patients, but the possible significance of this difference E. ARNOLD CARMICHAEL, M.B., M.R.C.P. LOND., has not been further studied. In Table II. are set CHIEF ASSISTANT, PROFESSORIAL MEDICAL UNIT, forth the results of testing the sera of 25 postST. BARTHOLOMEW’S HOSPITAL. encephalitic patients ; brief details are given of the history of their disease. Antibodies were found in Two main theories concerning the setiology of the serum of 18 out of 25 patients (or 72 per cent.), - encephalitis lethargica are current. Some hold that approximately the same percentage as in the control the disease is caused by the virus of herpes simplex, group. which under exceptional circumstances becomes All the patients whose serum was tested were whether or not they had ever suffered from neurotropic in man. This view is based on the asked occasional recovery of herpes virus from the brains " herpes simplex," the nature of which was described of patients dead of encephalitis lethargica and on to them. Very few replied in the affirmative, but it the fact that herpes virus can produce not only an is not felt that much reliance can be placed upon the acute or chronic encephalitis in rabbits, but also, answers obtained. In addition to the unselected as Zinsser has shown, a chronic encephalitis in group of normals in Table II., sera were examined certain monkeys which is not unlike encephalitis from seven subjects, all workers at the National lethargica in man. Others, however, are unconvinced Institute for Medical Research and all liable to by this evidence and maintain that the cause of frequently recurring attacks of labial herpes. Antiencephalitis lethargica is an unknown specific neuro- bodies were present in all seven of these sera. It tropic virus. (See Zinsser’s2 recent review of the is of particular interest that one of them had had an attack of herpes six days before he was bled, problem.) It seemed that some light might be thrown on the while another had an attack four days after blood was aetiology of encephalitis lethargica by examining sera taken. Herpes simplex is one of the few known virus
PRESENCE
OF
ANTIBODIES TO VIRUS
HERPES
858 One of us (E. A. C.) is responsible for the clinical diagnosis of the patients and for obtaining the sera; the other (0. H. A.) for the animal tests. We thank Prof. F. Fraser for permission to utilise the material under his care and Prof. Major Greenwood for kindly examining the available figures. He assures us that statistically there is no significant difference between the post-encephalitic and control sera either in our 4
diseases which does not lead to lasting immunity at least in man. It appears from these observations that in some obscure way herpes can recur in man despite the presence of antibodies in the serum. TABLE I.-Antibodies to
Herpes in Control Sera.
series
or
in that of Zinsser and
Tang.4
References. 1. Zinsser, H. : Jour. Exp. Med., 1929, xlix., 661. 2. : Archives of Pathology, 1928, vi., 271. ,, 3. Flexner, S. : Jour. Amer. Med. Assoc., 1923, lxxxi., 1785. 4. Zinsser, and Tang, F. F. : Jour. Immunol., 1929, xvii., 343. 5. Gay, F., and Holden, M. : Jour. Inf. Dis., 1929, xlv., 415. 6. Smith, Wilson: Jour. Path. and Bact., 1930, xxxiii., 273. 7. Andrewes, C. H. : Ibid., 1930, xxxiii., 301.
AN IMPROVED METHOD OF LIGATURING THE EXTERNAL CAROTID ARTERY. BY NORMAN PATTERSON, M.B., CH.B. EDIN.,
F.R.C.S. ENG., NOSE AND EAR LONDON HOSPITAL.
SURGEON, THROAT,
*
Medical student.
Ad. = Adult.
There
was no
herpes simplex in any patient except Case 22 and history in Case 19.
IT occurred to me some time ago that the operation of ligature of the external carotid might be simplified. I have on two occasions carried out a modified procedure which I am convinced possesses definite advantages over the classical method. The preliminary stages of the operation are the same as those described in the text-books. The carotid sheath is exposed and
history of a
DEPARTMENT,
doubtful
TABLE II.-Antibodies to Herpes in Postencephalitic S’era.
incisect
over
zne
internal jjugularr vein, which is freed from
its
fascial
covering for a length of from 2 to 3 inches in the
neighbourhood responding to
cor-
the
region of the carotid bifurcation. vein is now
The
carefully separated underlying structures, including the vagus nerve.
from
It is then retracted towards the mesial plane, instead of laterally as in the classical operation, until the bifurcation of the common carotid comes into view. The hyponerve tends to be retracted forwards with the vein and may never come into sight ; of course, care must be taken to avoid damaging this nerve or its branch, the descendens hypoglossi. The actual ligation of the I external carotid is carried out at the site of election by adopting the same technique as in the classical procedure. Sometimes it may be advisable to tie the ascending pharyngeal artery. In uncomplicated cases this method is simpler than the older one.
glossal
Parkinsonism was present in all the cases. There was a doubtful history of herpes simplex in Cases 35 and 38, but no history in any other patient.
Yet that serum can prevent the virus from infecting rabbit’s skin or a tissue culture of rabbits’ testis.
a
Summary. Antibodies to herpes virus
were found in the serum of 72 per cent. of 25 patients with post-encephalitic parkinsonism and in 75 per cent. of 28 unselected controls. These observations, therefore, lend no support to the view that the virus of herpes simplex is the essential cause of encephalitis lethargica. Seven subjects with frequently recurring labial herpes all had antibodies in their sera ; the significance of this is discussed.
I
Difficulty of the Recognised Route. operation by the recognised route may be extremely difficult, where there is a regular plexus of large veins over the bifurcation of the carotid and more especially if in addition there are enlarged glands, the seat of acute or chronic inflammation, possibly associated with adhesions. The veins which The