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ECHOVIRUS TYPE 30 AND MENINGITIS
1029
estimated
cost. In Greater London, 131 orders to cost E1,619,417 to execute cost in
that
were
fact only E677.839. In some instances only 1 affected householder in 3 applied for a grant. Some had ensured smokeless conditions before the order was made, and some simply burnt premium fuels on existing open grates. But apparently only 40% of possible claims were made. Industrial air pollution, on the other hand, is apparently proving tractable. The society asked 1714 authorities how present estimated emission of smoke, dust, and grit from local industries compared with that in 1956. Only 1 in 3 replied, but their answers suggested that industrial smoke emission had been almost halved, while the emission of dust and grit had been cut to three-fifths. Light industries, and laundries in particular, were most often mentioned as sources of continuing pollution.
expected
WHAT’S IN A NAME?
THERE have long been complaints that official of drugs are too long, seldom easy to pronounce, and give little or no indication of their activity. In short, they are not memorable, and this is probably why periodic campaigns to encourage prescribing by approved rather than proprietary names have always failed. Just possibly it needs to be shown that factors which have long been known to affect the ease of remembering in the psychological laboratoryact in the same way in real life, and the Research Project on Prescribing2 at the University of Liverpool has recently chosen two rather indirect ways of doing this.3 First, 45 drug names in the B.N.F. were all found to have chemical derivations, as against only 45 out of 116 in the Monthly Index of Medical Specialities; and chemically based names are not very useful to busy doctors.
names
Second, 9 three-syllable drug names were made up (three or Greek, three chemical, and three pharmacological), and 3 other names of four or five syllables were Latin
taken from the U.S.P. One from each of these four categories was attached to each of three therapeutic classes -central sedative/hypnotics, central stimulants, and purgatives-and 64 clinical students were invited to guess in which of the three classes the experimenters had placed the 9 imaginary drugs and the 3 U.S.P. real ones.
The American drugs were as often misplaced although in a non-random way: and subjects and menters also disagreed over 2 of the fictitious 9.
as
not,
experiAgreement was almost perfect, perhaps not very surprisingly, about the fictitious names barbamyl ", oblivam ", and enemax "-names so suggestive that if they do not almost already exist it will be surprising if they are not soon invented. Indeed, the 12 names chosen in this study were almost as likely to be thought to have sedative action as either of the other two actions put together. (It does not seem to be generally known that most people expect an unknown drug to be a depressant rather than anything else.) It is a pity that the conclusions which can safely be drawn from this interesting little study seem limited: the sample was too small to permit confident hypotheses about the reasons for correct or incorrect definitions. Perhaps a more direct and larger study using the classical method "
"
"
,
1. Ebbinghaus, H. Über das Gedächtnis. Leipzig, 1885. 2. See Lancet, April 11, 1964, p. 803. 3. Bromley, D. B., Korte, S. M. T., Mapes, R. E. A., Wilson, C. W. M. Practitioner, 1964, 192, 388.
of paired associates4 will examine the factors determining the relative ease with which a larger number of names, concocted in accordance with predictions from up-to-date learning theory,5 evoke memories of the actions attributed to them-and, of course, the reverse. ECHOVIRUS TYPE 30 AND MENINGITIS
ALL the subgroups of the enteroviruses include some which tend to involve the nervous system. Polioviruses types 1 and 3 are strongly- neurotropic, the Coxsackie viruses of group B often cause aseptic meningitis, and some serotypes of group A do so at times. In epidemics of infection with ECHO viruses there have been many cases of aseptic meningitis; but certain serotypes of ECHO viruses are not known for certain to cause illnessthey are still " orphan " viruses " in search of a disease ". Among the new serotypes recently designated by the responsible group of American virologists is one-type 30-for which there is already good evidence of pathogenicity in man.6 Because not all the members of a serotype are antigenically identical, the group endeavours to select as the prototype for a new type a strain which induces antibody against a wide range of antigens shared by all its antigenic " relatives ", and for ECHO virus type 30 they have chosen the Bastianni strain. The first virus of this group to be reported was isolated in Scotland in 1959 and was called Frater virus. It was recovered from 69 cases in an epidemic of aseptic meningitis, and from 1 case with paralysis resembling poliomyelitis in which there was no evidence of infection with another paralytogenic enterovirus. The virus was recovered infrequently from cases of diarrhoea or respiratory disease. It was recovered more readily in human thyroid or amnion cells than in monkey-kidney cells; and serological tests showed that it had not infected the community very widely, for 9% of blood-donors had antibody before the epidemic and 25% after it. Similar viruses were reported in California (strain Price 8) and New York State (strain Bastianni 9). Many strains of another virus-Gileswere recovered in 1960 from cases of aseptic meningitis in Minnesota 10; in further cases infection was diagnosed by antibody titrations 11 on the patients’ sera. As in other studies it was noted that, although 75 strains of virus were recovered by inoculating clinical specimens (probably mainly faeces), into primary human amnion cells, only 2 strains were recovered using monkey-kidney cells and 3 using one line of HeLa cells. Viruses from all these outbreaks were non-pathogenic for several species of laboratory animals and did not hxmagglutinate. The epidemic in Minnesota occurred in July, August, and September, and the cases were distributed equally in age-groups between 5 and 30 years-such a high proportion of cases in adults is unlike infections with polioviruses or Coxsackie viruses and suggested that the virus had not previously been prevalent in that area. The main symptoms were stiff neck, headache, fever, and vomiting. About half the patients had muscular pains, and a quarter complained of sore throat. The white-blood-cell count in the cerebrospinal fluid was usually under 4. 5.
Calkins, M. W. Psychol. Rev. 1894, 1, 476. Woodworth, R. S., Schlosberg, H. Experimental Psychology. London,
1954. 6. Melnick, J. L. et al. Science, 1963, 141, 153 7. Duncan, I. B. R. Lancet, 1960, ii, 470; J. Hyg., Camb. 1961, 59, 181. 8. Lennette, E. H., Schmidt, N. J., Magoffin, L. L., Dennis, J., Wiener, A. Proc. Soc. exp. Biol., N.Y. 1962, 110, 769. 9. Plager, H., Decher, W. Amer. J. Hyg. 1963, 77, 26. 10. Cooney, M. K., McLaren, L. C., Bauer, H. ibid. 1963, 75, 301. 11. Kleinman, H., Cooney, M. K., Nelson, C. B., Owen, R. R., Boyd, L., Swanda, G. J. Amer. med. Ass. 1964, 187, 90.
1030 100 per c.mm., with mononuclear cells predominating. 3 patients (5% of the total) showed paralysis of groups of limb muscles which improved rapidly and recovered completely. Viruses were isolated from a few patients with undifferentiated minor illnesses, but no estimate of the frequency of such cases can be drawn from the published data. Thus the clinical features resemble those previously observed in Scotland. ECHO virus type 30 is the probable cause of some outbreaks of aseptic meningitis. Since antibodies against it are by no means universal it may be recovered in further epidemics, provided suitable tissue-cultures are used.
detected in the neonatal period. He doubted whether early diagnosis was very important for the treatment of cerebral palsy. On breaking the news of a handicap to the parents, Dr. John Apley suggested that the first telling should only be a prelude; the doctor should not tell lies, but should not necessarily tell the full truth at once, and indeed the parents may not be able to assimilate this immediately. It was nearly always wise, for the parents’ comfort, to have a second opinion. It was important to end with something positive. It was important, too, to see that all who would be helping the parents should present a consistent viewpoint. Following this there was, thought Dr. R. C. Mac Keith, a need for a continuity boy ". The efforts for child and family of general practitioner, local-authority clinic, and hospital consultant should be collated by one of "
THE HANDICAPPED CHILD AND HIS FAMILY
THE handicapped child and his family were discussed on May 2 and 3 at a weekend refresher course organised jointly by the Spastics Society and the Postgraduate Medical Federation. With the increasing survival of handicapped children, more and more children, and thus more and more families, need all the help that the community can give. In the words of Dr. Mary Sheridan, the handicapped child should not have more than the promising child, for it was on the future leadership given by the promising child that the wellbeing of the community would depend; but the handicapped child should have his full fair share of the resources. The National Health Service provided a splendid opportunity to give this fair share to the handicapped child, but only if all three branches cooperated efficiently. The main requirements were early diagnosis, complete assessment (and this may take months), prompt medical and surgical treatment, parental guidance including confident instruction of the mother and the full help of the local-authority services, appropriate education, and later appropriate placement in the community. Dr. R. D. C. Hart said that the general practitioner would be able to carry out detailed examination of infants for the very early diagnosis of hidden defects, such as mental retardation, cerebral palsy, and deafness, only at the expense of other activities. It was agreed that such examinations were well worth while in the " at-risk " group, selected because of an unfavourable family history, very low birth-weight, low birth-weight for length of gestation, severe neonatal jaundice, and other factors known to predispose to damage of the brain and special senses. The danger of making the mother anxious by repeated examination of the baby might be reduced by explaining the surveillance as a research study. On the techniques of early testing, Dr. A. N. Cammock said that the severe degrees of deafness, and even partial high-frequency deafness, should be diagnosed by the age of 5 months. The partly hearing child should, where appropriate, be wearing a hearing-aid by 9 months, and at the same time a peripatetic teacher should be allocated to the child and follow the child into the nursery-school and perhaps later into a special class of a primary school. For cerebral palsy, Dr. J. P. M. Tizard said that it was difficult to diagnose lesions of the cerebral hemispheres in the neonatal period: before the age of 2 months they played little part in the behaviour of the baby-though two early items which did involve the hemispheres were following the mother with the eyes, and following a diffuse (but not pinpoint) source of light. But if the cause of cerebral damage was very recent, such damage might be readily
them. The parents would often decide which it should be. He himself, as a consultant in charge of a cerebral-palsy clinic, would like to keep the collating in his own hands at least until the child entered school. Dr. K. S. Holt said that in the early stages rational planning by the family was impossible: they must be helped to overcome their anxieties first. Then attention must be given to the dangers of maternal overprotection or rejection of the child, of physical exhaustion of the mother, of social isolation of the family, and of excessive demands for help from the normal children in the family. Practical aids in the house might be needed. The parents should be helped to think about, and get good advice on, any further children they might have. Dr. C. 0. Carter described the role of specialist genetic clinics in giving information on such risks, which could be increasingly precise with new biochemical and cytogenetic tests. But it was agreed that even when the risk of the defect occurring also in a later child was small, the mother might need considerable encouragement to plan a further child, and support during the pregnancy. The local authority’s main task is in the provision of education, which, as Dr. J. D. Kershaw said, must be good, where necessary therapeutic, and ultimately vocational. The local authority might start the education of the handicapped child as early as 2 years-for example, in nurseryschools for partly hearing children or the blind; and, if the child had been formally ascertained, the authority had compulsory powers to continue education till 16 years. The plans and framework were sound, but there was difficulty in recruiting and training the specialist teachers. The local authority could also help the family through the domestic help and welfare services. It was agreed that there was lack of continuity in the care of the handicapped child on leaving school. A general practitioner who was also a local magistrate and on the local National Assistance Board, said that handicapped children from his practice too often appeared before him later in one of his other two capacities. Here the voluntary societies, as they had often in the past in special education, were showing a lead; the voluntary societies for the mentally retarded, spastic, blind, and deaf, and the Invalid Children’s Association, were pioneering the provision of careers and employment
guidance, hostels, and sheltered workshops handicapped adolescent and adult.
for the
THE next session of the General Medical Council will open Tuesday, May 26, at 2.15 P.M., when Lord Cohen of Birkenhead, the president, will deliver an address. The Disciplinary Committee will sit on Wednesday, May 27, at 10.30 A.M. on
estimated
cost. In Greater London, 131 orders to cost E1,619,417 to execute cost in
that
were
fact only E677.839. In some instances only 1 affected householder in 3 applied for a grant. Some had ensured smokeless conditions before the order was made, and some simply burnt premium fuels on existing open grates. But apparently only 40% of possible claims were made. Industrial air pollution, on the other hand, is apparently proving tractable. The society asked 1714 authorities how present estimated emission of smoke, dust, and grit from local industries compared with that in 1956. Only 1 in 3 replied, but their answers suggested that industrial smoke emission had been almost halved, while the emission of dust and grit had been cut to three-fifths. Light industries, and laundries in particular, were most often mentioned as sources of continuing pollution.
expected
WHAT’S IN A NAME?
THERE have long been complaints that official of drugs are too long, seldom easy to pronounce, and give little or no indication of their activity. In short, they are not memorable, and this is probably why periodic campaigns to encourage prescribing by approved rather than proprietary names have always failed. Just possibly it needs to be shown that factors which have long been known to affect the ease of remembering in the psychological laboratoryact in the same way in real life, and the Research Project on Prescribing2 at the University of Liverpool has recently chosen two rather indirect ways of doing this.3 First, 45 drug names in the B.N.F. were all found to have chemical derivations, as against only 45 out of 116 in the Monthly Index of Medical Specialities; and chemically based names are not very useful to busy doctors.
names
Second, 9 three-syllable drug names were made up (three or Greek, three chemical, and three pharmacological), and 3 other names of four or five syllables were Latin
taken from the U.S.P. One from each of these four categories was attached to each of three therapeutic classes -central sedative/hypnotics, central stimulants, and purgatives-and 64 clinical students were invited to guess in which of the three classes the experimenters had placed the 9 imaginary drugs and the 3 U.S.P. real ones.
The American drugs were as often misplaced although in a non-random way: and subjects and menters also disagreed over 2 of the fictitious 9.
as
not,
experiAgreement was almost perfect, perhaps not very surprisingly, about the fictitious names barbamyl ", oblivam ", and enemax "-names so suggestive that if they do not almost already exist it will be surprising if they are not soon invented. Indeed, the 12 names chosen in this study were almost as likely to be thought to have sedative action as either of the other two actions put together. (It does not seem to be generally known that most people expect an unknown drug to be a depressant rather than anything else.) It is a pity that the conclusions which can safely be drawn from this interesting little study seem limited: the sample was too small to permit confident hypotheses about the reasons for correct or incorrect definitions. Perhaps a more direct and larger study using the classical method "
"
"
,
1. Ebbinghaus, H. Über das Gedächtnis. Leipzig, 1885. 2. See Lancet, April 11, 1964, p. 803. 3. Bromley, D. B., Korte, S. M. T., Mapes, R. E. A., Wilson, C. W. M. Practitioner, 1964, 192, 388.
of paired associates4 will examine the factors determining the relative ease with which a larger number of names, concocted in accordance with predictions from up-to-date learning theory,5 evoke memories of the actions attributed to them-and, of course, the reverse. ECHOVIRUS TYPE 30 AND MENINGITIS
ALL the subgroups of the enteroviruses include some which tend to involve the nervous system. Polioviruses types 1 and 3 are strongly- neurotropic, the Coxsackie viruses of group B often cause aseptic meningitis, and some serotypes of group A do so at times. In epidemics of infection with ECHO viruses there have been many cases of aseptic meningitis; but certain serotypes of ECHO viruses are not known for certain to cause illnessthey are still " orphan " viruses " in search of a disease ". Among the new serotypes recently designated by the responsible group of American virologists is one-type 30-for which there is already good evidence of pathogenicity in man.6 Because not all the members of a serotype are antigenically identical, the group endeavours to select as the prototype for a new type a strain which induces antibody against a wide range of antigens shared by all its antigenic " relatives ", and for ECHO virus type 30 they have chosen the Bastianni strain. The first virus of this group to be reported was isolated in Scotland in 1959 and was called Frater virus. It was recovered from 69 cases in an epidemic of aseptic meningitis, and from 1 case with paralysis resembling poliomyelitis in which there was no evidence of infection with another paralytogenic enterovirus. The virus was recovered infrequently from cases of diarrhoea or respiratory disease. It was recovered more readily in human thyroid or amnion cells than in monkey-kidney cells; and serological tests showed that it had not infected the community very widely, for 9% of blood-donors had antibody before the epidemic and 25% after it. Similar viruses were reported in California (strain Price 8) and New York State (strain Bastianni 9). Many strains of another virus-Gileswere recovered in 1960 from cases of aseptic meningitis in Minnesota 10; in further cases infection was diagnosed by antibody titrations 11 on the patients’ sera. As in other studies it was noted that, although 75 strains of virus were recovered by inoculating clinical specimens (probably mainly faeces), into primary human amnion cells, only 2 strains were recovered using monkey-kidney cells and 3 using one line of HeLa cells. Viruses from all these outbreaks were non-pathogenic for several species of laboratory animals and did not hxmagglutinate. The epidemic in Minnesota occurred in July, August, and September, and the cases were distributed equally in age-groups between 5 and 30 years-such a high proportion of cases in adults is unlike infections with polioviruses or Coxsackie viruses and suggested that the virus had not previously been prevalent in that area. The main symptoms were stiff neck, headache, fever, and vomiting. About half the patients had muscular pains, and a quarter complained of sore throat. The white-blood-cell count in the cerebrospinal fluid was usually under 4. 5.
Calkins, M. W. Psychol. Rev. 1894, 1, 476. Woodworth, R. S., Schlosberg, H. Experimental Psychology. London,
1954. 6. Melnick, J. L. et al. Science, 1963, 141, 153 7. Duncan, I. B. R. Lancet, 1960, ii, 470; J. Hyg., Camb. 1961, 59, 181. 8. Lennette, E. H., Schmidt, N. J., Magoffin, L. L., Dennis, J., Wiener, A. Proc. Soc. exp. Biol., N.Y. 1962, 110, 769. 9. Plager, H., Decher, W. Amer. J. Hyg. 1963, 77, 26. 10. Cooney, M. K., McLaren, L. C., Bauer, H. ibid. 1963, 75, 301. 11. Kleinman, H., Cooney, M. K., Nelson, C. B., Owen, R. R., Boyd, L., Swanda, G. J. Amer. med. Ass. 1964, 187, 90.
1030 100 per c.mm., with mononuclear cells predominating. 3 patients (5% of the total) showed paralysis of groups of limb muscles which improved rapidly and recovered completely. Viruses were isolated from a few patients with undifferentiated minor illnesses, but no estimate of the frequency of such cases can be drawn from the published data. Thus the clinical features resemble those previously observed in Scotland. ECHO virus type 30 is the probable cause of some outbreaks of aseptic meningitis. Since antibodies against it are by no means universal it may be recovered in further epidemics, provided suitable tissue-cultures are used.
detected in the neonatal period. He doubted whether early diagnosis was very important for the treatment of cerebral palsy. On breaking the news of a handicap to the parents, Dr. John Apley suggested that the first telling should only be a prelude; the doctor should not tell lies, but should not necessarily tell the full truth at once, and indeed the parents may not be able to assimilate this immediately. It was nearly always wise, for the parents’ comfort, to have a second opinion. It was important to end with something positive. It was important, too, to see that all who would be helping the parents should present a consistent viewpoint. Following this there was, thought Dr. R. C. Mac Keith, a need for a continuity boy ". The efforts for child and family of general practitioner, local-authority clinic, and hospital consultant should be collated by one of "
THE HANDICAPPED CHILD AND HIS FAMILY
THE handicapped child and his family were discussed on May 2 and 3 at a weekend refresher course organised jointly by the Spastics Society and the Postgraduate Medical Federation. With the increasing survival of handicapped children, more and more children, and thus more and more families, need all the help that the community can give. In the words of Dr. Mary Sheridan, the handicapped child should not have more than the promising child, for it was on the future leadership given by the promising child that the wellbeing of the community would depend; but the handicapped child should have his full fair share of the resources. The National Health Service provided a splendid opportunity to give this fair share to the handicapped child, but only if all three branches cooperated efficiently. The main requirements were early diagnosis, complete assessment (and this may take months), prompt medical and surgical treatment, parental guidance including confident instruction of the mother and the full help of the local-authority services, appropriate education, and later appropriate placement in the community. Dr. R. D. C. Hart said that the general practitioner would be able to carry out detailed examination of infants for the very early diagnosis of hidden defects, such as mental retardation, cerebral palsy, and deafness, only at the expense of other activities. It was agreed that such examinations were well worth while in the " at-risk " group, selected because of an unfavourable family history, very low birth-weight, low birth-weight for length of gestation, severe neonatal jaundice, and other factors known to predispose to damage of the brain and special senses. The danger of making the mother anxious by repeated examination of the baby might be reduced by explaining the surveillance as a research study. On the techniques of early testing, Dr. A. N. Cammock said that the severe degrees of deafness, and even partial high-frequency deafness, should be diagnosed by the age of 5 months. The partly hearing child should, where appropriate, be wearing a hearing-aid by 9 months, and at the same time a peripatetic teacher should be allocated to the child and follow the child into the nursery-school and perhaps later into a special class of a primary school. For cerebral palsy, Dr. J. P. M. Tizard said that it was difficult to diagnose lesions of the cerebral hemispheres in the neonatal period: before the age of 2 months they played little part in the behaviour of the baby-though two early items which did involve the hemispheres were following the mother with the eyes, and following a diffuse (but not pinpoint) source of light. But if the cause of cerebral damage was very recent, such damage might be readily
them. The parents would often decide which it should be. He himself, as a consultant in charge of a cerebral-palsy clinic, would like to keep the collating in his own hands at least until the child entered school. Dr. K. S. Holt said that in the early stages rational planning by the family was impossible: they must be helped to overcome their anxieties first. Then attention must be given to the dangers of maternal overprotection or rejection of the child, of physical exhaustion of the mother, of social isolation of the family, and of excessive demands for help from the normal children in the family. Practical aids in the house might be needed. The parents should be helped to think about, and get good advice on, any further children they might have. Dr. C. 0. Carter described the role of specialist genetic clinics in giving information on such risks, which could be increasingly precise with new biochemical and cytogenetic tests. But it was agreed that even when the risk of the defect occurring also in a later child was small, the mother might need considerable encouragement to plan a further child, and support during the pregnancy. The local authority’s main task is in the provision of education, which, as Dr. J. D. Kershaw said, must be good, where necessary therapeutic, and ultimately vocational. The local authority might start the education of the handicapped child as early as 2 years-for example, in nurseryschools for partly hearing children or the blind; and, if the child had been formally ascertained, the authority had compulsory powers to continue education till 16 years. The plans and framework were sound, but there was difficulty in recruiting and training the specialist teachers. The local authority could also help the family through the domestic help and welfare services. It was agreed that there was lack of continuity in the care of the handicapped child on leaving school. A general practitioner who was also a local magistrate and on the local National Assistance Board, said that handicapped children from his practice too often appeared before him later in one of his other two capacities. Here the voluntary societies, as they had often in the past in special education, were showing a lead; the voluntary societies for the mentally retarded, spastic, blind, and deaf, and the Invalid Children’s Association, were pioneering the provision of careers and employment
guidance, hostels, and sheltered workshops handicapped adolescent and adult.
for the
THE next session of the General Medical Council will open Tuesday, May 26, at 2.15 P.M., when Lord Cohen of Birkenhead, the president, will deliver an address. The Disciplinary Committee will sit on Wednesday, May 27, at 10.30 A.M. on