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COMPULSORY IMMUNISATION
795
Letters
to
the Editor
CARBON-MONOXIDE POISONING SiR,-Those of us who come in contact with the reality of carbon-monoxide poisoning are greatly indebted to Drs. McMichael and Ruskin for their comprehensive study in your issue of Nov. 30. The idea of open-air collapse, due to the absence of carbon dioxide in the fresh air, is particularly interesting. Some five years ago a very skilled chief officer of a large rescue station drew my attention to the frequency of collapse, especially in those cases in which artificial respiration had been performed, with oxygen as an adjunct. I accounted for the condition by a supply of CO2 in the blood insufficient to stimulate the respiratory centre, bearing in mind that usually the period of rescue was prolonged, that during unconsciousness less CO2 was made-especially with some of the blood-oxygen replaced by carbon monoxide-and that artificial respiration of pure oxygen washed out vital COz from the air cells of the lungs and reduced its concentration in the blood. My informant has since used a mixture of 10 per cent..C02 and oxygen in poisonous atmospheres, and free CO2 in ordinary air, and I have not recently heard of any collapse or relapse of serious nature. I doubt whether this open-air collapse will be generally accepted as due to the new atmosphere without C02. In my own experience amongst firemen, whose work naturally gives them mixed gases, I have not noted it except after exertion. The typical symptoms, as related by the victim, are a buzzing or throbbing of the head, a giddiness or feeling of uselessness of the limbs,. followed by some mental confusion which tends to argumentative excitement. If they rescue themselves and remain in the air, sensible enough to sit down and exaggerate their breathing, the effects soon pass away. Chief officers are warned to watch the period of excitement and to keep the breathing exaggerated in fresh air if necessary by free use of CO2, By this means the carbon monoxide is readily eliminated, usually before collapse and unconsciousness. Reports from all over the kingdom convince me that the sooner breathing can be exaggerated in the fresh air the more perfect will be recovery. The so-called delayed symptoms of carbon-monoxide poisoning are not due to the continued presence of the gas in the blood, but to the damage done to cell structure during the stage of anoxia. Artificial respiration is rarely necessary, and if it is performed without added CO2 unconsciousness is unnecessarily prolonged. In fresh air oxygen is not essential, and the time wasted in procuring it may be the factor to determine life or death. The early-indeed the immediate-use of CO2 is essential is all cases ; almost every fire brigade in the land carries a small supply of it. GILBERT BURNET, Chief Surgeon, N.F.B.A. Hemel Hempstead.
PNEUMOCOCCAL MENINGITIS
SiR,—Dr. Falla (Lancet, Nov. 30,
p. 698) doubts the accuracy of Squadron Leader Coleman’s figure of 35% for the present mortality-rate in pneumococcal meningitis. Dr. Falla suggests that the figure is probably too and that in fact the mortality is still optimistic " extremely high." I find that 10 cases of pneumococcal meningitis have been admitted to the Royal Hampshire County Hospital under my care since August, 1938, and 4 other cases of purulent meningitis, probably pneumococcal, from which the causal organism could not be recovered. In this admittedly small series there have been no deaths. All cases have been treated with sulphapyridine in ordinary doses and by repeated lumbar puncture. In the adult cases 2 g. of sulphapyridine was given, either by mouth or by injection, as the initial ’dose ; this was repeated in four hours and then followed by 1 g. four-hourly. In 2 cases, after apparent control of the infection and a reduction in the drug, clinical relapse appeared which was readily subdued by increasing the dose to2 g. again. The remaining cases all responded rapidly and went on to complete cure without interruption. The most dramatic case was that of a woman of 24, seven months pregnant, admitted to hospital semi-comatose after two days severe headache ;
her condition had been diagnosed as toxaemia. Her cerebrospinal fluid appeared as frank pus and was swarming with pneumococci. She was discharged cured in ten days and in due course gave birth to healthy twins. Others could no doubt tell similar stories and I wonder whether the suggested mortality-rate of 35% . is not in fact considerably too high. The pneumococcus seems to me more easily destroyed by sulphapyridine in the meninges than in any other situation. Repeated removal of the purulent cerebrospinal fluid has seemed an important part of treatment, analogous to the removal of pus from the pleural cavity in pneumococcal empyema, where drainage is essential for cure even when sulphapyridine treatment has rendered the empyema
sterile.
Winchester.
KENNETH ROBERTSON.
COMPULSORY IMMUNISATION
SiR,—Dr. Killick Millard’s comments call for amplification of my letter ofNov. 16. Among other things I suggested compulsory active immunisation against
diphtheria for all school-children-the term to be used not in a strict legal sense but to include all who are attending nursery and infant schools. There has been and will continue to be a growing exodus of the child population from crowded centres of population to reception areas and the chief danger of the spread of diphtheria will be in the schools. The only practical way of carrying out immunisation in a short time is by close cooperation with the education authorities in the school clinics where it is possible to combine medical supervision with the keeping of records. Immunisation on a voluntary basis would, of course, still be available for the remainder of the child population, but all authorities which have conscientiously undertaken diphtheria immunisation schemes will appreciate how difficult it is to deal quickly with this group. Reduction in the number of cases of diphtheria would help to solve our most immediate problems by allowing us to use the sparse isolation accommodation in reception areas to the best advantage. Judging from my own experience over a number of years, and from the remarkable successes reported by several medical officers of health in their own areas, the failure of voluntary schemes of immunisation, taking the country as a whole, is not due, as many would have us believe, to opposition from the parents, but rather to the failure of many public-health authorities properly to contact the people. Dr. Millard emphasised his conviction born of long experience that compulsory measures would fail to achieve the desired result and cited as an example the intense opposition which resulted from the attempt in this country, years ago, to make small-pox vaccination really compulsory ; but I would point out that the chief arguments elaborated at that time by a small but influential section of the community to bring vaccination into disrepute cannot be advanced with fairness where injections of diphtheria alum toxoid, T.A.B. vaccine and tetanus toxoid are concerned. As several weeks are required to develop the immune state after a course of injections it does not appear to me a wise policy to wait until the epidemic starts before widespread schemes of immunisation are attempted-which appears to be the official view at the moment. It is an unhappy thought that epidemics of infectious disease can decimate the population to an extent which does not appear possible even from the direct effects of the most severe aerial attack. I hope the medical profession will voice their disapproval of the present " wait and see
generally
policy. Edgware, Middlesex.
..
A. A. CUNNINGHAM.
BLOOD-UREA AND PLASMA CHLORIDE IN EXPERIMENTAL HÆMORRHAGE SIR,-The rise of blood-urea after haemorrhage is most likely due to the fall of blood-pressure and very probably has nothing to do with the haemorrhage as such. We invariably found a rise in blood-urea after lowering the blood-pressure by various methods other than venesection. Blood-pressure aids the renal function-a fact not generally recognised-and a hypotonic condition impairs this function, in consequence of which urea accumulates in the blood. In regard to chlorides, we never succeeded in raising blood chlorides consistently, even after the
‘
.
Letters
to
the Editor
CARBON-MONOXIDE POISONING SiR,-Those of us who come in contact with the reality of carbon-monoxide poisoning are greatly indebted to Drs. McMichael and Ruskin for their comprehensive study in your issue of Nov. 30. The idea of open-air collapse, due to the absence of carbon dioxide in the fresh air, is particularly interesting. Some five years ago a very skilled chief officer of a large rescue station drew my attention to the frequency of collapse, especially in those cases in which artificial respiration had been performed, with oxygen as an adjunct. I accounted for the condition by a supply of CO2 in the blood insufficient to stimulate the respiratory centre, bearing in mind that usually the period of rescue was prolonged, that during unconsciousness less CO2 was made-especially with some of the blood-oxygen replaced by carbon monoxide-and that artificial respiration of pure oxygen washed out vital COz from the air cells of the lungs and reduced its concentration in the blood. My informant has since used a mixture of 10 per cent..C02 and oxygen in poisonous atmospheres, and free CO2 in ordinary air, and I have not recently heard of any collapse or relapse of serious nature. I doubt whether this open-air collapse will be generally accepted as due to the new atmosphere without C02. In my own experience amongst firemen, whose work naturally gives them mixed gases, I have not noted it except after exertion. The typical symptoms, as related by the victim, are a buzzing or throbbing of the head, a giddiness or feeling of uselessness of the limbs,. followed by some mental confusion which tends to argumentative excitement. If they rescue themselves and remain in the air, sensible enough to sit down and exaggerate their breathing, the effects soon pass away. Chief officers are warned to watch the period of excitement and to keep the breathing exaggerated in fresh air if necessary by free use of CO2, By this means the carbon monoxide is readily eliminated, usually before collapse and unconsciousness. Reports from all over the kingdom convince me that the sooner breathing can be exaggerated in the fresh air the more perfect will be recovery. The so-called delayed symptoms of carbon-monoxide poisoning are not due to the continued presence of the gas in the blood, but to the damage done to cell structure during the stage of anoxia. Artificial respiration is rarely necessary, and if it is performed without added CO2 unconsciousness is unnecessarily prolonged. In fresh air oxygen is not essential, and the time wasted in procuring it may be the factor to determine life or death. The early-indeed the immediate-use of CO2 is essential is all cases ; almost every fire brigade in the land carries a small supply of it. GILBERT BURNET, Chief Surgeon, N.F.B.A. Hemel Hempstead.
PNEUMOCOCCAL MENINGITIS
SiR,—Dr. Falla (Lancet, Nov. 30,
p. 698) doubts the accuracy of Squadron Leader Coleman’s figure of 35% for the present mortality-rate in pneumococcal meningitis. Dr. Falla suggests that the figure is probably too and that in fact the mortality is still optimistic " extremely high." I find that 10 cases of pneumococcal meningitis have been admitted to the Royal Hampshire County Hospital under my care since August, 1938, and 4 other cases of purulent meningitis, probably pneumococcal, from which the causal organism could not be recovered. In this admittedly small series there have been no deaths. All cases have been treated with sulphapyridine in ordinary doses and by repeated lumbar puncture. In the adult cases 2 g. of sulphapyridine was given, either by mouth or by injection, as the initial ’dose ; this was repeated in four hours and then followed by 1 g. four-hourly. In 2 cases, after apparent control of the infection and a reduction in the drug, clinical relapse appeared which was readily subdued by increasing the dose to2 g. again. The remaining cases all responded rapidly and went on to complete cure without interruption. The most dramatic case was that of a woman of 24, seven months pregnant, admitted to hospital semi-comatose after two days severe headache ;
her condition had been diagnosed as toxaemia. Her cerebrospinal fluid appeared as frank pus and was swarming with pneumococci. She was discharged cured in ten days and in due course gave birth to healthy twins. Others could no doubt tell similar stories and I wonder whether the suggested mortality-rate of 35% . is not in fact considerably too high. The pneumococcus seems to me more easily destroyed by sulphapyridine in the meninges than in any other situation. Repeated removal of the purulent cerebrospinal fluid has seemed an important part of treatment, analogous to the removal of pus from the pleural cavity in pneumococcal empyema, where drainage is essential for cure even when sulphapyridine treatment has rendered the empyema
sterile.
Winchester.
KENNETH ROBERTSON.
COMPULSORY IMMUNISATION
SiR,—Dr. Killick Millard’s comments call for amplification of my letter ofNov. 16. Among other things I suggested compulsory active immunisation against
diphtheria for all school-children-the term to be used not in a strict legal sense but to include all who are attending nursery and infant schools. There has been and will continue to be a growing exodus of the child population from crowded centres of population to reception areas and the chief danger of the spread of diphtheria will be in the schools. The only practical way of carrying out immunisation in a short time is by close cooperation with the education authorities in the school clinics where it is possible to combine medical supervision with the keeping of records. Immunisation on a voluntary basis would, of course, still be available for the remainder of the child population, but all authorities which have conscientiously undertaken diphtheria immunisation schemes will appreciate how difficult it is to deal quickly with this group. Reduction in the number of cases of diphtheria would help to solve our most immediate problems by allowing us to use the sparse isolation accommodation in reception areas to the best advantage. Judging from my own experience over a number of years, and from the remarkable successes reported by several medical officers of health in their own areas, the failure of voluntary schemes of immunisation, taking the country as a whole, is not due, as many would have us believe, to opposition from the parents, but rather to the failure of many public-health authorities properly to contact the people. Dr. Millard emphasised his conviction born of long experience that compulsory measures would fail to achieve the desired result and cited as an example the intense opposition which resulted from the attempt in this country, years ago, to make small-pox vaccination really compulsory ; but I would point out that the chief arguments elaborated at that time by a small but influential section of the community to bring vaccination into disrepute cannot be advanced with fairness where injections of diphtheria alum toxoid, T.A.B. vaccine and tetanus toxoid are concerned. As several weeks are required to develop the immune state after a course of injections it does not appear to me a wise policy to wait until the epidemic starts before widespread schemes of immunisation are attempted-which appears to be the official view at the moment. It is an unhappy thought that epidemics of infectious disease can decimate the population to an extent which does not appear possible even from the direct effects of the most severe aerial attack. I hope the medical profession will voice their disapproval of the present " wait and see
generally
policy. Edgware, Middlesex.
..
A. A. CUNNINGHAM.
BLOOD-UREA AND PLASMA CHLORIDE IN EXPERIMENTAL HÆMORRHAGE SIR,-The rise of blood-urea after haemorrhage is most likely due to the fall of blood-pressure and very probably has nothing to do with the haemorrhage as such. We invariably found a rise in blood-urea after lowering the blood-pressure by various methods other than venesection. Blood-pressure aids the renal function-a fact not generally recognised-and a hypotonic condition impairs this function, in consequence of which urea accumulates in the blood. In regard to chlorides, we never succeeded in raising blood chlorides consistently, even after the
‘
.