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AN UNUSUAL EPIDEMIC
1091 their construction is very much more robust formerly, when a rheostat was essential for their protection. As regards electrical contacts, it is surely the business of the anaesthetist to see that, like the rest of his apparatus, the laryngoscope is functioning properly before he uses it. I. 1. W. MAGILL. London, W.I.
adays;
than
AN UNUSUAL EPIDEMIC
SiR,—I give further details of the epidemic which I described in your issue of Aug. 6. Since then fifty further specimens of serum have been examined and found to be negative for antibodies against the A.P.C. group of viruses. It must now be concluded that this epidemic is not due to any of the known strains of the A.p.c.-virus group ; but in view of certain similarities in the clinical picture to that caused by the A.p.c.-virus group, the possibility that the epidemic may be due to a hitherto unknown strain of this group cannot yet be excluded. Unfortunately attempted isolation of the presumptive virus in tissue-culture has had to be postponed owing to the great pressure of work on virus laboratories; so any identification is at present impossible. It seems possible to me that cases similar to these in this epidemic may have occurred elsewhere, and it would be most interesting to hear whether this has been so. I should like to expand slightly the general account of features met in this epidemic-features not necessarily found in every case, for the symptoms have been protean. The main symptoms have been as follows : can now
1. Dull frontal headache, with retro-orbital pain. 2. General malaise, vertigo, and lack of energy and concentration. Tüe vertigo, which is a constant feature, may be affected by posture and be severe at times. Incoördination is evident in some cases ; there may, for instance, be difficulty in pouring tea into cups at the first attempt and breakage of ’
crockery by normally sure-fingered people. 3. Eye symptoms. The eyes feel gritty and in most cases they water freely. Conjunctivitis (usually mild, and later phlyctenular) may appear at an early stage ; sometimes it is unilateral. Photophobia occurs in the more severe cases at the onset, and diplopia has been complained of in some cases. Vision is usually affected to some extent ; usually vision is described as blurred. 4. Upper-respiratory inflammation is common, and the patient may present with a harsh irritating tracheal type of cough. Sore throat is usually transient but may persist, causing dysphagia, or pain and discomfort in the mornings and evenings which ease off through the day. 5. Adenitis. This may be general or mainly restricted to the cervical chain. The glands are firm, rubbery to palpation, and tender. 6. The patient may present with abdominal symptoms -transient diarrhoea and vomiting, with flatulent distension and tenderness over the costal margin on each side. Some patients have severe epigastric pain and occasionally pain in the right iliac fossa, which is usually described as colicky." Frequency of micturition with dysuria is an occasional symptom. The tongue is invariably heavily coated. 7. Myalgia, particularly affecting the paraspinal muscles, is common, as is a feeling of weakness and tiredness in the lower limbs. Night cramps are also usual, and some patients have remarked on a feeling of deadness " at times in both upper and lower limbs, followed by " pins and needles." Reflexes in general are sluggish. 8. Skin rashes have occurred in some of those affected. These have been morbilliform and transient, lasting 36-48 hours, in children aged 3 weeks to 14 years and have been accompanied by a temperature of 99-100°F. A few other children and adults have had irritating raised lumps, with vesiculation, varying from a few to full body coverage and lasting several weeks before clearing. Several adults had a severe urticarial rash. An enanthem has been more usual, consisting of red maculopapules on the palate with creamy necrotic centres. 9. Many of the patients are sleepy by day and restless "
"
by night.
10. Recurrence of
valescence.
symptoms is
Recurrence may
common
persist
throughout
for several
days,
con-
with
headache, stiff neck,
watering eyes, sore throat, and dizziness, among other symptoms. 11. In different patients the temperature and pulse-rate vary from subnormal to 104°F and 130 per min. at the onset. 12. Weight loss is usual and may be considerable-e.g., 14 lb. over a period of several weeks in a child aged 6 years. 13. While the majority of patients recover after several weeks, in a not inconsiderable proportion symptoms persist with exacerbations over a period of months. In conclusion I should like to thank Dr. B. E. Andrews, of the Central Public Health Laboratory, Colindale, for his kindness in examining sera from these cases, and Dr. D. G. Davies, director of the Public Health Laboratory, Carlisle, and Dr. K. J. Thomson, medical officer of health to the Border Rural District Council, for their continued interest and help. A. L. WALLIS. Dalston, Cumberland. THE EXCRETION OF RADIOACTIVE IODINE IN HUMAN MILK
SiR,-Last week’s article by Dr. Miller and Dr. Weetch,
confirming the concentration of radio-iodine in human milk,l gives a valuable warning, although it is fair to state that few tests of thyroid function now require a dose of 131 as high as 25 c. In their last sentence—" Radioactive iodine should not be given to a nursing mother "-I believe from the context that the words " radioactive iodine " may have been used for 131 I." If a test has to be made in such circumstances, it is the outstanding advantage of 132I that this short-lived isotope of iodine, used for a twohour uptake test, can be given in rather smaller doses than 131I, and causes less than 0.5% as much thyroid irradiation per microcurie as 1. Even if a nursing mother received an adequate test dose of 4 (ic. of 132I and did not interrupt feeding, the infant’s thyroid, on the worst figures given by Miller and Weetch, would only receive 0.04 r.e.p. instead of the 50 r.e.p. from the 25 .c. dose of l31I about which they are rightly anxious. Department of Clinical Research, University College Hospital Medical E. ERIC POCHIN. School, London, W.C.1. ARGENTAFFIN CARCINOMA
SiR,-In their description last week of a case of argentaffin carcinoma, Dr. Goble and his colleagues refer to the improvement in symptoms and the fall in serum 5-hydroxytryptamine (5-H.T.) and daily urinary 5-H.T. excretion after treatment with
193A.u, and make that these changes would be interesting suggestion explained by the mactivation of a naturally occurring Another possibility mono-amine oxidase inhibitor. deserves to be considered. Dr. Goble and his collaborators observed a severe temporary granulocytopenia but make no mention of changes in the platelet-count ; after a large dose of radioactive gold this might well have fallen also. With much free 5-H.T. in the plasma the platelets would be already saturated and a fall in their number would lead to a fall in serum 5-H.T. which might account for all or part of that observed. What effect a fall in blood 5-H.T. occasioned in this way might have on symptoms and 5-H.T. excretion, cannot at present be said. It would be interesting to know whether thrombocytopenia in fact occurred. Finally, may I point out that the striking difference observed in the 5-H.T. content of serum derived from blood from the right and left sides of the heart accords with the observation by Gaddum et a1.2 that the perfused cat lung removes free 5-H.T. from the perfusing blood. Department of Therapeutics, St. Thomas’s Hospital, R. S. STACEY. London, S.E.1.
the
Honour, A. J., Myant, N. B., Rowlands, E. N. Clin. Sci. 1952, 11, 447. 2. Gaddum, J. H., Hebb, C. O., Silver, A., Swan, A, A. B. Quart. J. exp. Physiol. 1953, 38, 255. 1.
adays;
than
AN UNUSUAL EPIDEMIC
SiR,—I give further details of the epidemic which I described in your issue of Aug. 6. Since then fifty further specimens of serum have been examined and found to be negative for antibodies against the A.P.C. group of viruses. It must now be concluded that this epidemic is not due to any of the known strains of the A.p.c.-virus group ; but in view of certain similarities in the clinical picture to that caused by the A.p.c.-virus group, the possibility that the epidemic may be due to a hitherto unknown strain of this group cannot yet be excluded. Unfortunately attempted isolation of the presumptive virus in tissue-culture has had to be postponed owing to the great pressure of work on virus laboratories; so any identification is at present impossible. It seems possible to me that cases similar to these in this epidemic may have occurred elsewhere, and it would be most interesting to hear whether this has been so. I should like to expand slightly the general account of features met in this epidemic-features not necessarily found in every case, for the symptoms have been protean. The main symptoms have been as follows : can now
1. Dull frontal headache, with retro-orbital pain. 2. General malaise, vertigo, and lack of energy and concentration. Tüe vertigo, which is a constant feature, may be affected by posture and be severe at times. Incoördination is evident in some cases ; there may, for instance, be difficulty in pouring tea into cups at the first attempt and breakage of ’
crockery by normally sure-fingered people. 3. Eye symptoms. The eyes feel gritty and in most cases they water freely. Conjunctivitis (usually mild, and later phlyctenular) may appear at an early stage ; sometimes it is unilateral. Photophobia occurs in the more severe cases at the onset, and diplopia has been complained of in some cases. Vision is usually affected to some extent ; usually vision is described as blurred. 4. Upper-respiratory inflammation is common, and the patient may present with a harsh irritating tracheal type of cough. Sore throat is usually transient but may persist, causing dysphagia, or pain and discomfort in the mornings and evenings which ease off through the day. 5. Adenitis. This may be general or mainly restricted to the cervical chain. The glands are firm, rubbery to palpation, and tender. 6. The patient may present with abdominal symptoms -transient diarrhoea and vomiting, with flatulent distension and tenderness over the costal margin on each side. Some patients have severe epigastric pain and occasionally pain in the right iliac fossa, which is usually described as colicky." Frequency of micturition with dysuria is an occasional symptom. The tongue is invariably heavily coated. 7. Myalgia, particularly affecting the paraspinal muscles, is common, as is a feeling of weakness and tiredness in the lower limbs. Night cramps are also usual, and some patients have remarked on a feeling of deadness " at times in both upper and lower limbs, followed by " pins and needles." Reflexes in general are sluggish. 8. Skin rashes have occurred in some of those affected. These have been morbilliform and transient, lasting 36-48 hours, in children aged 3 weeks to 14 years and have been accompanied by a temperature of 99-100°F. A few other children and adults have had irritating raised lumps, with vesiculation, varying from a few to full body coverage and lasting several weeks before clearing. Several adults had a severe urticarial rash. An enanthem has been more usual, consisting of red maculopapules on the palate with creamy necrotic centres. 9. Many of the patients are sleepy by day and restless "
"
by night.
10. Recurrence of
valescence.
symptoms is
Recurrence may
common
persist
throughout
for several
days,
con-
with
headache, stiff neck,
watering eyes, sore throat, and dizziness, among other symptoms. 11. In different patients the temperature and pulse-rate vary from subnormal to 104°F and 130 per min. at the onset. 12. Weight loss is usual and may be considerable-e.g., 14 lb. over a period of several weeks in a child aged 6 years. 13. While the majority of patients recover after several weeks, in a not inconsiderable proportion symptoms persist with exacerbations over a period of months. In conclusion I should like to thank Dr. B. E. Andrews, of the Central Public Health Laboratory, Colindale, for his kindness in examining sera from these cases, and Dr. D. G. Davies, director of the Public Health Laboratory, Carlisle, and Dr. K. J. Thomson, medical officer of health to the Border Rural District Council, for their continued interest and help. A. L. WALLIS. Dalston, Cumberland. THE EXCRETION OF RADIOACTIVE IODINE IN HUMAN MILK
SiR,-Last week’s article by Dr. Miller and Dr. Weetch,
confirming the concentration of radio-iodine in human milk,l gives a valuable warning, although it is fair to state that few tests of thyroid function now require a dose of 131 as high as 25 c. In their last sentence—" Radioactive iodine should not be given to a nursing mother "-I believe from the context that the words " radioactive iodine " may have been used for 131 I." If a test has to be made in such circumstances, it is the outstanding advantage of 132I that this short-lived isotope of iodine, used for a twohour uptake test, can be given in rather smaller doses than 131I, and causes less than 0.5% as much thyroid irradiation per microcurie as 1. Even if a nursing mother received an adequate test dose of 4 (ic. of 132I and did not interrupt feeding, the infant’s thyroid, on the worst figures given by Miller and Weetch, would only receive 0.04 r.e.p. instead of the 50 r.e.p. from the 25 .c. dose of l31I about which they are rightly anxious. Department of Clinical Research, University College Hospital Medical E. ERIC POCHIN. School, London, W.C.1. ARGENTAFFIN CARCINOMA
SiR,-In their description last week of a case of argentaffin carcinoma, Dr. Goble and his colleagues refer to the improvement in symptoms and the fall in serum 5-hydroxytryptamine (5-H.T.) and daily urinary 5-H.T. excretion after treatment with
193A.u, and make that these changes would be interesting suggestion explained by the mactivation of a naturally occurring Another possibility mono-amine oxidase inhibitor. deserves to be considered. Dr. Goble and his collaborators observed a severe temporary granulocytopenia but make no mention of changes in the platelet-count ; after a large dose of radioactive gold this might well have fallen also. With much free 5-H.T. in the plasma the platelets would be already saturated and a fall in their number would lead to a fall in serum 5-H.T. which might account for all or part of that observed. What effect a fall in blood 5-H.T. occasioned in this way might have on symptoms and 5-H.T. excretion, cannot at present be said. It would be interesting to know whether thrombocytopenia in fact occurred. Finally, may I point out that the striking difference observed in the 5-H.T. content of serum derived from blood from the right and left sides of the heart accords with the observation by Gaddum et a1.2 that the perfused cat lung removes free 5-H.T. from the perfusing blood. Department of Therapeutics, St. Thomas’s Hospital, R. S. STACEY. London, S.E.1.
the
Honour, A. J., Myant, N. B., Rowlands, E. N. Clin. Sci. 1952, 11, 447. 2. Gaddum, J. H., Hebb, C. O., Silver, A., Swan, A, A. B. Quart. J. exp. Physiol. 1953, 38, 255. 1.