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ENCEPHALOPATHY AND PERTUSSIS VACCINATION
630 and within 24 hours of the injection of streptokinase practical ] difficulty may be illustrated from the work large volumes of blood were easily removed. In a of CATHIE 7 in this country. He has apparently had patient with a postoperative effusion infected with considerable success in the treatment of tuberculous Ps. pyocyanea more than a litre of bloodstainedmeningitis by adding streptokinase to intrathecal fluid was evacuated after the injection of strepto; of streptomycin. The enzyme was prepared injections kinase, but the remaining infection resisted all forms by a modification of the method described by GARNER of treatment until streptodornase was injected on and TILLETT in 1934 s; the filtrate of the broth culture alternate days ; after the third injection of this the is adsorbed on to aluminium hydroxide and eluted pleura was sterile. It is thought that the removal of with phosphate solution, and the product is standarthe exudate and debris allowed the natural antibacterial dised against clots formed in dilute plasma by the factors, cellular and humoral, to make better contact addition of thrombin. Even with this simpler method with the bacilli and to destroy them. Photomicro- the routine supply of streptokinase is a considerable graphs of pus from a maxillary sinus show how addition to the work of a hospital laboratory. Pro20 minutes after the injection of streptodornase the duction by CHRISTENSEN’s method of the presumably whole background of debris in the film had dispurer and more potent preparations, which are probappeared, only living leucocytes being left. The enzymes ably essential for the treatment of large pleural were also useful in chronic osteomyelitis with sinus effusions, would be impracticable. The American formation and spreading ulceration of the skin. workers say that much of their material was supplied " Streptococcal enzymatic debridement," as TILLETT by Messrs. Lederle and Co. and it is satisfactory to and his colleagues call their new technique for the know that an active preparation of streptokinase removal of blood-clot and the cleansing of infected can be obtained in England.* surfaces, is likely to be of great value as a supplement 7. Cathie, I. A. B. J. clin. Path. 1949, 2, 73 ; Lancet, 1949, i, 441. to antibiotic therapy in suitable cases, if only in 8. Garner, R. L., Tillett, W. S. J. exp. Med., 1934, 60, 239. makers Messrs Burroughs Wellcome, do not state the conshortening the patient’s illness and lessening the * Thecentration of desoxyribonuclease in their product, but in a rough formation of fibrous tissue. But it is clearly not a titration a sample of sticky tuberculous pus was liquefied in vitro by moderate dilutions of the enzyme. The enzyme is simple matter to arrange for the supply of the enzymes supplied in the dry form to be dissolved immediately before in adequate concentration, purity, and volume. This use.
Annotations ENCEPHALOPATHY AND PERTUSSIS VACCINATION in infants and young appear among the major It has been estimated that causes of child deaths. of normal children have a convulsion 4-7% apparently before they are 5 years old. Most of these attacks are associated with pyrexial illnesses, particularly respiratory infections lasting only a day or two. Some 5-10% are followed by epilepsy in later life. Violent and focal convulsions often leave* cerebral sequelae, especially if they occur before the child is a year old, and Lennox,l who followed up 240 cases of febrile convulsions, found nervous instability of some kind in 10-15% of the children; she emphasised that fever with convulsions can produce brain damage detectable in an electroencephalogram. A convulsion or coma is the most usual first symptom of the ill-defined group of cerebral disturbances called encephalopathies, and there seems to be no sharp dividing line between these and the postconvulsive state. In some of them there is a definite cause of cerebral irritation, such as lead-poisoning or uraemia, but in most cases the reason for the cerebral symptoms is obscure. Clinically it is difficult if not impossible to distinguish the encephalopathies associated with infections from postinfective encephalitis, and even the pathological differentiation is uncertain. Grouping these manifestations together it may be said that temporary, permanent, or even fatal cerebral disturbances occur in scarlet fever (Rolleston 2 collected records of 75 cases with hemiplegia), smallpox, measles, mumps, herpes zoster, typhoid fever, and pertussis. The cerebral symptoms usually appear with or after the rash, but Holliday 3 has lately published examples of " encephalitis " arising in the pre-eruptive stage of rubella, measles, and chickenpox, and this condition should be borne in mind whenever a child develops obscure
CONVULSIONS
are
children, though they
1.
Common
no
longer
Lennox, M. A. J. Pediat. 1949, 35, 427 ; Amer. J. Dis. Child. 1949, 78, 868. 2. Rolleston, J. D. Proc. R. Soc. Med. 1927, 21, 213. 3. Holliday, P. B. J. Pediat. 1950, 36, 185.
after being in contact with infection. The most puzzling of the "encephalopathies" are those which follow prophylactic inoculations. Sometimes this is a chance association (there has been at least one instance of a child having a severe convulsion a quarter of an hour before a dose of vaccine), but smallpox vaccination and rabies or T.A.B. inoculations are undoubtedly, though very rarely, the cause of encephalitic symptoms. In the U.S.A. there have been
neurological symptoms
reports ofe encephalopathy ascribed to pertussis vaccine, though again the incidence is very low in relation to the 2½-3million inoculations done every year. There have been no similar cases after diphtheria immunisation alone, which suggests that in the two recent cases in England following combined diphtheria=pertussis inoculation the pertussis vaccine was the cause. In both cases, oddly enough, the children had twin brothers who
immunised at the same time without ill effects. In both the injection was their first dose. The first case4 was in a boy of 8 months who started a convulsion about eight hours after his injection and died in hospital seven or eight hours later. Autopsy showed only intense and some oedema of the whole brain. In the congestion case reported by Dr. Anderson and Dr. Morris last week (p. 537) the boy was older (2 years 7 months) and had had a convulsion with transient hemiplegia three months before, when other children in the house had mumps; his convulsions did not start until thirty -six hours after his immunisation. Fortunately this child recovered, though with a right hemiparesis ; the encephalograms showed dilatation of the left lateral ventricle. The mechanism of these mishaps is unknown. H. pertussis does contain an endotoxin which, when injected into rabbits will cause death in convulsions : but this does not happen if the vaccine has been treated with heat or formalin, and presumably its action can be ruled out here. The possible explanations seem to be: " some sensitisation phenomenon " ; a latent encephalopathic tendency, made manifest by the vaccine ; a latent virus infection similarly activated ; or a cerebral vascular accident, such as thrombosis of small cerebral vessels, which is supported by the rapidity of onset of the symptoms. were
4. Brit. med. J.
1949, ii, 1478.
631 Whatever the explanation, it seems wise not to give pertussis vaccine if there is a past history of convulsions, if the child is suffering from or has recently had a respiratory or other infection, or he has lately been in contact with an infection to which he is susceptible. DAY HOSPITALS ONE out of every thirty-five people born in Great Britain (Dr. E. B. Strauss says 1) is at some time or another a certified patient in a mental hospital. This is a dramatic way of putting the fact that the incidence of certifiable mental illness in the community is nearly 3%, and it certainly helps the imagination to grasp the problem in terms of people and families. Certified patients of course represent only a proportion of the mentally ill in the country ; there are just as many people seeking voluntary treatment in our mental hospitals, and there are many more who do not need full hospital treatment but who badly need help of some kind. For some years now the mental service has been trying to find ways of helping these people. Outpatient clinics at mental and general hospitals do something, social clubs for discharged mental-hospital patients perhaps do more. Community care given by psychiatric socal workers to patients in their own homes has already proved its worth 2 ; and the day hospital started by the Institute of Social Psychiatry has benefited many who feel themselves to be in some sense outcasts from society -discharged patients, neurotics, psychopaths, and delinquents among them. The institute opened its first social clubs for patients over ten years ago, and is now responsible for some 11 of them. The idea of a day hospital came to Dr. Joshua Bierer, the director of the institute, through his growing conviction that some of these patients needed more help than they gained from an hour or two a week, or even an hour or two a day, of social intercourse. The day hospital offers them fully occupied days : it provides group and individual treatment, occupational therapy throughout the day, art, music, and drama, and the opportunity to adapt themselves to a society which is, indeed, selected and experienced under safeguarded conditions, but which is nevertheless real-demanding appropriate behaviour and the acceptance of responsibility, and offering treatment at the level of actual personal experience. Every patient has his effect on the group : even withdrawal, as Dr. Strauss pointed out, has its effect, attracting some and repelling others. The day hospital thus differs from the mental hospital in providing an opportunity for emotional development. The inpatient can go his own way without affecting the group because he has no responsibility. The patient in a day hospital is one of a group in action : he gets the rewards or buffets which his own behaviour excites and he is directly affected by the behaviour of others. It might be thought that society as a whole could provide him with this experience. It always had to do it in the past, and sometimes no doubt the results were good. The current unsociability of our race is responsible for a good deal of ostracism, and no doubt of expense. We have to make artificial opportunities for social intercourse for various groups of people-the aged, the residents of new housing estates, the mentally sick, the deaf, the blind, the troublesome, the’lonely. In more genial days the general zest of society must have carried all these people along, and no-oneseems to have been the worse. Now we withdraw our garments, and fear to be bored or distressed. This has some bearing on the question raised by a ’
’
-
_
probation officer
at last
week’s conference ; she asked
March 22, at a conference on Day Hospitals Speaking by the Institute for Social Psychiatry. 2. See Lancet, Feb. 4, p. 216. 1.
on
arranged
"
whether there was no danger of contamination " : whether one neurotic would not confirm another in his symptoms-whether, in short, the day hospital was not brewing up an explosive mixture. Dr. Bierer was able to reply that they had not found it to be so, either in the clubs or the day hospital ; but then they take their precautions, diluting the more explosive elements by getting their wives and families to join the clubs with them. In one experimental club where discharged criminals are members, psychiatric social worker students make the leaven. This particular club was actually started because discharged criminals can find no company but their own kind ; nobody else will accept them, and this in itself predisposes them to offend again. The really antisocial person, Dr. Bierer said, cannot help fighting society, because he feels like a cornered rat : against " You will never remove his sense of being cornered by cornering him further." Our police, he reminded the meeting, carry no firearms ; and fewer of them get killed than in any other country, Our criminals, he said, feel less cornered. SOCIAL HISTORY OF THE WAR Mr. Titmuss’s Problems of- Social Policyis one of the United Kingdom Civil Series of the History of the Second World War. The basic data of his themes are simply stated : " One metric ton of high-explosive, dropped in night raids by piloted aircraft on large cities in Britain, killed about four to five people and injured between ten to fifteen.... When the raids came, the size and character of the problem of homelessness took the authorities by surprise. In general terms one ton of high-explosive delivered on the built-up area of London and other large cities destroyed or damaged repair ten houses. Another twenty-five were rendered temporarily uninhabitable and eighty were slightly damaged. On the average, therefore, one ton affected 115 houses, made eighty people temporarily homeless and caused another thirty-five to lose their homes permanently. For every civilian killed, thirty-five were bombed , out of their
beyond
homes." In sum, 60,000 civilians were killed, 86,000 were seriously and 149,000 slightly injured. 175,000 houses were destroyed, 201,000 were damaged and rendered uninhabitable for a period, and 3,034,000 had minor damage. Millions of citizens-expectant and nursing mothers and children-were evacuated from the danger areas under official schemes or privately. So strong was the pull of family life (and often so uncomfortable was the strain of living with strangers) that as the incidence of bombing dropped, so the evacuees tended to return, and as it waxed anew, so the evacuation process had to be repeated. But
each time fewer went,. and more effort was needed to persuade them to go. So’we have the three main themes of this book-the problems of evacuation, of the homeless, and of casualties -and in their unfolding Mr. Titmuss leads us both wide and deep. He divides his history into four parts : Expected War, The Invisible War, The Battles, and The Long Years. The pre-war plans, their shortcomings in face of ’the actual event, the effect on one another of evacuee and (often unwilling) host Treasury, parsimony, local-authority reluctance to incur expenditure, the poor-law traditions, of chargeability," the comparative blind spot on problems arising from housing damage, the transformation in outlook produced by the first week’s blitzon London and the subsequent rapid development of post-raid services, the national nutrition policy, the excessive curtailment of some of "
1. Problems of Social Policy. By RICHARD M. TITMUSS. London : H.M. Stationery Office and Longmans, Green. 1950. Pp. 596.
25s.
Annotations ENCEPHALOPATHY AND PERTUSSIS VACCINATION in infants and young appear among the major It has been estimated that causes of child deaths. of normal children have a convulsion 4-7% apparently before they are 5 years old. Most of these attacks are associated with pyrexial illnesses, particularly respiratory infections lasting only a day or two. Some 5-10% are followed by epilepsy in later life. Violent and focal convulsions often leave* cerebral sequelae, especially if they occur before the child is a year old, and Lennox,l who followed up 240 cases of febrile convulsions, found nervous instability of some kind in 10-15% of the children; she emphasised that fever with convulsions can produce brain damage detectable in an electroencephalogram. A convulsion or coma is the most usual first symptom of the ill-defined group of cerebral disturbances called encephalopathies, and there seems to be no sharp dividing line between these and the postconvulsive state. In some of them there is a definite cause of cerebral irritation, such as lead-poisoning or uraemia, but in most cases the reason for the cerebral symptoms is obscure. Clinically it is difficult if not impossible to distinguish the encephalopathies associated with infections from postinfective encephalitis, and even the pathological differentiation is uncertain. Grouping these manifestations together it may be said that temporary, permanent, or even fatal cerebral disturbances occur in scarlet fever (Rolleston 2 collected records of 75 cases with hemiplegia), smallpox, measles, mumps, herpes zoster, typhoid fever, and pertussis. The cerebral symptoms usually appear with or after the rash, but Holliday 3 has lately published examples of " encephalitis " arising in the pre-eruptive stage of rubella, measles, and chickenpox, and this condition should be borne in mind whenever a child develops obscure
CONVULSIONS
are
children, though they
1.
Common
no
longer
Lennox, M. A. J. Pediat. 1949, 35, 427 ; Amer. J. Dis. Child. 1949, 78, 868. 2. Rolleston, J. D. Proc. R. Soc. Med. 1927, 21, 213. 3. Holliday, P. B. J. Pediat. 1950, 36, 185.
after being in contact with infection. The most puzzling of the "encephalopathies" are those which follow prophylactic inoculations. Sometimes this is a chance association (there has been at least one instance of a child having a severe convulsion a quarter of an hour before a dose of vaccine), but smallpox vaccination and rabies or T.A.B. inoculations are undoubtedly, though very rarely, the cause of encephalitic symptoms. In the U.S.A. there have been
neurological symptoms
reports ofe encephalopathy ascribed to pertussis vaccine, though again the incidence is very low in relation to the 2½-3million inoculations done every year. There have been no similar cases after diphtheria immunisation alone, which suggests that in the two recent cases in England following combined diphtheria=pertussis inoculation the pertussis vaccine was the cause. In both cases, oddly enough, the children had twin brothers who
immunised at the same time without ill effects. In both the injection was their first dose. The first case4 was in a boy of 8 months who started a convulsion about eight hours after his injection and died in hospital seven or eight hours later. Autopsy showed only intense and some oedema of the whole brain. In the congestion case reported by Dr. Anderson and Dr. Morris last week (p. 537) the boy was older (2 years 7 months) and had had a convulsion with transient hemiplegia three months before, when other children in the house had mumps; his convulsions did not start until thirty -six hours after his immunisation. Fortunately this child recovered, though with a right hemiparesis ; the encephalograms showed dilatation of the left lateral ventricle. The mechanism of these mishaps is unknown. H. pertussis does contain an endotoxin which, when injected into rabbits will cause death in convulsions : but this does not happen if the vaccine has been treated with heat or formalin, and presumably its action can be ruled out here. The possible explanations seem to be: " some sensitisation phenomenon " ; a latent encephalopathic tendency, made manifest by the vaccine ; a latent virus infection similarly activated ; or a cerebral vascular accident, such as thrombosis of small cerebral vessels, which is supported by the rapidity of onset of the symptoms. were
4. Brit. med. J.
1949, ii, 1478.
631 Whatever the explanation, it seems wise not to give pertussis vaccine if there is a past history of convulsions, if the child is suffering from or has recently had a respiratory or other infection, or he has lately been in contact with an infection to which he is susceptible. DAY HOSPITALS ONE out of every thirty-five people born in Great Britain (Dr. E. B. Strauss says 1) is at some time or another a certified patient in a mental hospital. This is a dramatic way of putting the fact that the incidence of certifiable mental illness in the community is nearly 3%, and it certainly helps the imagination to grasp the problem in terms of people and families. Certified patients of course represent only a proportion of the mentally ill in the country ; there are just as many people seeking voluntary treatment in our mental hospitals, and there are many more who do not need full hospital treatment but who badly need help of some kind. For some years now the mental service has been trying to find ways of helping these people. Outpatient clinics at mental and general hospitals do something, social clubs for discharged mental-hospital patients perhaps do more. Community care given by psychiatric socal workers to patients in their own homes has already proved its worth 2 ; and the day hospital started by the Institute of Social Psychiatry has benefited many who feel themselves to be in some sense outcasts from society -discharged patients, neurotics, psychopaths, and delinquents among them. The institute opened its first social clubs for patients over ten years ago, and is now responsible for some 11 of them. The idea of a day hospital came to Dr. Joshua Bierer, the director of the institute, through his growing conviction that some of these patients needed more help than they gained from an hour or two a week, or even an hour or two a day, of social intercourse. The day hospital offers them fully occupied days : it provides group and individual treatment, occupational therapy throughout the day, art, music, and drama, and the opportunity to adapt themselves to a society which is, indeed, selected and experienced under safeguarded conditions, but which is nevertheless real-demanding appropriate behaviour and the acceptance of responsibility, and offering treatment at the level of actual personal experience. Every patient has his effect on the group : even withdrawal, as Dr. Strauss pointed out, has its effect, attracting some and repelling others. The day hospital thus differs from the mental hospital in providing an opportunity for emotional development. The inpatient can go his own way without affecting the group because he has no responsibility. The patient in a day hospital is one of a group in action : he gets the rewards or buffets which his own behaviour excites and he is directly affected by the behaviour of others. It might be thought that society as a whole could provide him with this experience. It always had to do it in the past, and sometimes no doubt the results were good. The current unsociability of our race is responsible for a good deal of ostracism, and no doubt of expense. We have to make artificial opportunities for social intercourse for various groups of people-the aged, the residents of new housing estates, the mentally sick, the deaf, the blind, the troublesome, the’lonely. In more genial days the general zest of society must have carried all these people along, and no-oneseems to have been the worse. Now we withdraw our garments, and fear to be bored or distressed. This has some bearing on the question raised by a ’
’
-
_
probation officer
at last
week’s conference ; she asked
March 22, at a conference on Day Hospitals Speaking by the Institute for Social Psychiatry. 2. See Lancet, Feb. 4, p. 216. 1.
on
arranged
"
whether there was no danger of contamination " : whether one neurotic would not confirm another in his symptoms-whether, in short, the day hospital was not brewing up an explosive mixture. Dr. Bierer was able to reply that they had not found it to be so, either in the clubs or the day hospital ; but then they take their precautions, diluting the more explosive elements by getting their wives and families to join the clubs with them. In one experimental club where discharged criminals are members, psychiatric social worker students make the leaven. This particular club was actually started because discharged criminals can find no company but their own kind ; nobody else will accept them, and this in itself predisposes them to offend again. The really antisocial person, Dr. Bierer said, cannot help fighting society, because he feels like a cornered rat : against " You will never remove his sense of being cornered by cornering him further." Our police, he reminded the meeting, carry no firearms ; and fewer of them get killed than in any other country, Our criminals, he said, feel less cornered. SOCIAL HISTORY OF THE WAR Mr. Titmuss’s Problems of- Social Policyis one of the United Kingdom Civil Series of the History of the Second World War. The basic data of his themes are simply stated : " One metric ton of high-explosive, dropped in night raids by piloted aircraft on large cities in Britain, killed about four to five people and injured between ten to fifteen.... When the raids came, the size and character of the problem of homelessness took the authorities by surprise. In general terms one ton of high-explosive delivered on the built-up area of London and other large cities destroyed or damaged repair ten houses. Another twenty-five were rendered temporarily uninhabitable and eighty were slightly damaged. On the average, therefore, one ton affected 115 houses, made eighty people temporarily homeless and caused another thirty-five to lose their homes permanently. For every civilian killed, thirty-five were bombed , out of their
beyond
homes." In sum, 60,000 civilians were killed, 86,000 were seriously and 149,000 slightly injured. 175,000 houses were destroyed, 201,000 were damaged and rendered uninhabitable for a period, and 3,034,000 had minor damage. Millions of citizens-expectant and nursing mothers and children-were evacuated from the danger areas under official schemes or privately. So strong was the pull of family life (and often so uncomfortable was the strain of living with strangers) that as the incidence of bombing dropped, so the evacuees tended to return, and as it waxed anew, so the evacuation process had to be repeated. But
each time fewer went,. and more effort was needed to persuade them to go. So’we have the three main themes of this book-the problems of evacuation, of the homeless, and of casualties -and in their unfolding Mr. Titmuss leads us both wide and deep. He divides his history into four parts : Expected War, The Invisible War, The Battles, and The Long Years. The pre-war plans, their shortcomings in face of ’the actual event, the effect on one another of evacuee and (often unwilling) host Treasury, parsimony, local-authority reluctance to incur expenditure, the poor-law traditions, of chargeability," the comparative blind spot on problems arising from housing damage, the transformation in outlook produced by the first week’s blitzon London and the subsequent rapid development of post-raid services, the national nutrition policy, the excessive curtailment of some of "
1. Problems of Social Policy. By RICHARD M. TITMUSS. London : H.M. Stationery Office and Longmans, Green. 1950. Pp. 596.
25s.