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LUMBAR PUNCTURE IN POLIOMYELITIS
492 Dutch doctor had little support for his diagnosis of argyria, but, unlike the rest of us, he had seen a case. Even psychiatric problems came up for our consideration, and we all agreed that the exuberant gentleman who went for a swim at 6 A.M. each morning, and played ferocious pingpong after every meal, could take a thricedaily dose of phenobarbitone with advantage. We also enjoyed discussing natural conditions of work and exchanging nomenclature. I was interested to hear that the Continental physician is called a specialist of internal diseases, and my colleagues were astounded to learn that, under our beneficent health service, most of the patients I now see have no disease, external or internal. *
*
*
I remember having a conversation some 25 years ago with a Cornishman who thought his county was not particularly beautiful (as well he might for he lived in Bodmin) ; but he added, " There is nothing to beat a I thought of him again as I picked Cornish lane." blackberries from one this summer. The myriad of stones which form the walls are there, I suppose, because it was the easiest way of stacking them when they were taken from the fields, which would certainly be unproductive if they remained there. Nine tiers of stones ; a span each is a usual formation, and, as each stone is often less than an inch broad, in some places there must be over 3000 stones to a yard, and double that for both sides. The loose earth between the stones nourishes a profusion of wild flowers, the gorse with its prickly stalk and bright yellow flower, and the red heather standing erect, the wild poppy, mustard, toadflax, scabious, bladder-campion, knapweed, tansy, and lady’s bedstraw sticking their heads sideways, with their yellow, purple, red, and green shades which would make a lovely design for a carpet. Perhaps a yard away, ferns grow in abundance in every shade of green, and, lastly, thyme with its delicate pink and delectable smell. I have put it last, not because it is the smallest but because it might perhaps go unnoticed if it had no scent. Did Shakespeare put it first because his sense of smell made him notice the bank, and then his roving, observant eye picked out the others ? Picking blackberries in a Cornish lane from the top of a bank which they shared with blue sloes and scarlet hawthorn berries made me realise how truly Bacon wrote when he said, " God Almighty first planted a garden." Wilderness still has its charm. * * * Our Peripatetic Parliamentary correspondent writes : In the passage by the House of the second reading of the National Health Service (D.D.) Amendment Bill as an agreed measure, an important step has been taken to close a gap in our system of social security. In moving its adoption, the Minister of Agriculture and Fisheries said he was proud to be associated with a measure which would provide every type of health care for the Darling Doggies. It had long been felt anomalous that in this country, which had pioneered so many social advances and which abounded in D.D.-lovers, the welfare of our four-footed friends still depended as much on private and voluntary effort as in the days of Gellert and Hodge. (A hon. member : Hodge was a cat.) He apologised, Crichel had rather got him Down, he should have said Flush. All kennels in the country, with the exception of disclaimed dog-baskets, would be administered from the Appointed Day by regional, group, and local kennel boards and committees. In view of the importance of nutrition to health, bones would be provided free of charge or at cost price through the maternal and puppy welfare clinics. Thanks to his friends the bloodhounds, no inroads would be made on the existing transfusion services. He hoped that the day had dawned when the phrase " a dog’s life " would take on a new meaning, and he felt sure that hon. members of all parties would metaphorically lift their hands-he had nearly said * legs-in support. * * From the Anglo-Saxon Chronicle for the
year A.D. 1086-" It very severe year, and a very sorrowful year in England ; and corn and crops were checked, and there was such great misfortune with the weather as cannot easily he conceived. There were such big thunderstorms and such lightning, so that many people were killed, and it kept getting worse and worse among the people, more and more so. May God Almighty make things better." was a
Letters
to
the Editor
LUMBAR PUNCTURE IN POLIOMYELITIS
SIR,—Your correspondents deprecating the perform. of lumbar puncture in cases of poliomyelitis seem
ance
to have allowed their enthusiasm to outrun their dis. means let us dispense with lumbar paralysis has occurred and the diagnosis is certain, though one may still be deceived by the occasional Gruillain-Barre in which sensory signs are minimal
cretion.
puncture
By
all
when
not looked for. But in so-called abortive poliomyelitis the situation is very different. Briefly, in this country at the present time, a patient presenting with acute neck and back stiffness usually has : (1) poliomyelitis ; (2) incipient meningitis (coccal, bacterial, or leptospiral) ; (3) any of the other viral meningo-encephalitides (including perhaps glandular fever and erythema multiforme) ; or (4) subarachnoid haemorrhage. What is one to do then ? Is it suggested that one should wait, thereby wasting precious, and it might well be vital, time until some unmistakable clinical development forces one’s hand ; or attempt by means of lumbar puncture to make a differential diagnosis at onceThe latter is the course which, in my view, one is bound, in the patient’s interest, to follow. (Incidentally, if the waiting policy were widely adopted, subarachnoid haemorrhage might rarely be diagnosed during life.) In any event the large number of cases of nonparalytic poliomyelitis that come into hospital, undergo lumbar puncture, and depart unscathed must surely suggest that the occasions when puncture precipitates paralysis must be exceedingly few. Moreover, the large measure of common agreement between the ratio of non-paralytic to paralytic cases in outbreaks all over the world again suggests that puncture can have no very decisive influence. in altering the balance. The question was debated briefly at the first poliomyelitis conference held in New York in 1948, when the majority opinion ran counter to your correspondents’ views. Finally, are we not becoming a little too " poliomyelitis At this hospital, in striking contrast to conscious " ’? previous years, we have had only one case "of paralytic poliomyelitis since January. Two " bulbars proved to be examples of Guillain-Barré syndrome. Moreover, the " majority of the " abortives would seem to have been mumps, as shown by subsequent clinical developments, or suggested by the findings in the fluid, complementfixation tests, and/or a significant rise in the serum or
amylase. I must apologise for stressing the obvious but it would be intolerable if your correspondents’ contention-that it is bad practice to do a lumbar puncture in cases of suspected poliomyelitis—were to be generally accepted and perhaps subsequently quoted against us in courts of law. South Middlesex Hospital, E. Isleworth. Islewortli.
G. E. BREEN. BREED.
SIR,—Your correspondents are to be supported in their views that undue interference and disturbance in dealing with the poliomyelitis patient in the preparalytic stages of the disease is to be deprecated, and that lumbar puncture in the case where diagnosis is without doubt should best be omitted. I know of no statistical evidence, however, to support the theory that lumbar puncture is a factor precipitating paralysis, and, indeed, experience in this hospital has never given rise to any suspicion of such a reaction. There have been a great many instances where the operation was performed in non-paralytic cases in the meningeal phase and where no paralysis followed. The unpredictable nature of this disease must make untenable any argument that where paralysis followed or increased the cause must be the lumbar
493 it must be as logical to attempt where patients with clinical evidence of accept that, received antiserum and did not neutralising poliomyelitis develop paralysis, this happy state must be attributed to the serum. Those of us with diagnostic units have much opportunity to observe the diseases admitted as suspected poliomyelitis and know only too well how common it is to meet cases with a meningeal reaction clinically indistinguishable from the preparalytic phase of that disease. The information gained from a diagnostic puncture has been invaluable in allowing early and life-saving treatment to begin in many cases of tuberculous and septic meningitis. Conservatism, as advocated by your correspondents, will almost certainly lead to many tragedies. Dr. Albury advocates " specialists " for lumbar puncture. This is obviously impracticable. The operation of lumbar puncture can be efficiently performed with minimal trauma or discomfort by those who have been instructed in the correct technique and have the right eoumment.
puncture.
As
a
corollary,
to
The Western Hospital,
London, S.W.6.
W. HOWLETT KELLEHER
DRUGS THROUGH THE LETTER BOX a household containing two doctors, we are inundated with medical advertisements. As the letters drop on the doormat, they are pounced on by the children, to be distributed to their owners. All advertisements are counted as the children’s " spoil," to be used for cutting out or learning their letters. We find this a satisfactory arrangement and only occasionally salvage a blotter, as we need one. Sometimes this peaceful state of affairs is disrupted by the arrival of samples of drugs by letter post. We have trained the 31f2-year-olds never to open packets of pills or to taste any, so they obediently hand them to us and watch wonderingly while we flush them down the lavatory. Now that our youngest is crawling, the problem has struck us again with renewed strength and we are driven to ask if nothing can be done about what is, in effect, a recurrent peril to medical households with children. Could not all drug manufacturers agree to send a card, to be returned by those who require samples ? Or will it be necessary to press for legislation to prevent the mailing of dangerous drugs to unwilling recipients? SUSANNA ISAACS. London, N.3.
SIR,-As
THE HUMALACTOR
I reply to Dr. Waller’s comments (Aug. 21) the humalactor’? I start with a disclaimer : this invention, called by Dr. Waller" Dr. Gunther’s contraption," is in no way mine and I have no connection with it whatsoever beyond trying it out and finding it useful. Medical inventions of all kinds—drugs, devices, and methods of management—deserve dispassionate appraisal and this I had sought to provide for the humalactor in my brief article on its use. Dr. Waller does not like the humalactor and sees in it a deterrent to the training of midwives and mothers in the technique of manual expression of breast secretion. No-one should fail to recognise the great contributions Dr. Waller has made to understanding the nursing mother and the processes of breastfeeding ; yet, while paying tribute to all he has done and to Dr. Waller himself, with the affection and respect which years of friendship have strengthened, I have thought it right to try other methods. Hospitals differ in their resources in personnel and also in the cases they receive. Many women find manual expression repugnant and, certainly, some nurses should not be taught, neither should they practise, manual expression on mothers in the early puerperium, when breasts are so tender and easily injured. Our mastitis rate has, in fact, risen on
SiR,-May
on
each of the four occasions when we have introduced Because of thie frequent early manual expression. failure and because early engorgement causes much suffering, alternative methods shortly to be described are used to reduce the incidence of engorgement of the breasts in this hospital-hence the relative smallness of the volumes of surplus milk removed by the humalactor. The severest censure in Dr. Waller’s letter is that reliance on a machine will render midwives and doctors content to let the patients manage as best they can when they go home. To me this is an illogical conclusion and an unjustifiable charge. Midwives .are not made more considerate by being driven to perform hurtful practices on difficult and engorged breasts, nor does recognition of the tenderness of breasts in the first week prevent a nurse or doctor from providing mothers with means to empty their breasts if necessary later. We find that if engorgement is avoided and if the department does not glory in the numerical pride of excess milk, most mothere go home contentedly and adequately feeding their babies and seldom have to do more than keep a watchful eye for excess secretion. Nor are failures as common as Dr. Waller’s reckoning would suggest : the humalactor, when we had only one machine, was used on those who had difficulties. At present we try to teach mothers the skill of manual expression before delivery and rely on the method where we deem necessary, but not, if we can help it, before the fifth day. The humalactor’s characteristics seemed worth describing since they differ happily from those of all other breast-pumps I know. I would agree with Dr. Waller’s matron that these others can stay unrepaired, or, where I have so often seen and leftthem, "lost" in a cupboard. Obstetric Hospital, University College Hospital, London, W.C.1.
MAVIS GUNTHER.
TERMINOLOGY IN LACTATIONAL PHYSIOLOGY
SIR,—On Sept. 7, the British Association is to hold a session of its agriculture and physiology sections,
joint
and the subject has been announced as The Physiology of Milk Liberation. The discussion will deal with the reflex which causes movements of milk from secretory alveoli in which it is stored to duct spaces near the teat, which occurs when the baby animal feeds and which is known as the draught reflex in women and as the let-down in cows. We think that the new term, liberation," is an unsuitable word for this process, for it suggests that the milk is held back and then released, and the term brings to mind a relaxation of a sphincter or the escape of the secretion across a membrane. We think the term ejection," introduced in a valuable extension1 of Folley’s excellent scheme2 setting out the phases of lactation, is also unsuitable, because milk is but rarely ejected, although the pressure within the duct is increased by the reflex. The same consideration applies to the term "
"
"
expulsion." Propulsion " "
seems to us to be preferable to any other of the terms so far suggested, for it connotes an active transportion of milk, it is without misleading implications, and it is widely used in the practice of human lactation. We think its general acceptance would make for easier understanding by those coming to know for the first time of the movement of milk in the
breast
or
mammary
gland.
We take this opportunity of
protesting strongly against suggestion of Cowie et al.l that in lactational physiology the verb " to suckle " should be used for what the baby animal does to get milk from the mamma—and for nothing else. To suckle means (o.E.D.) to "give suck the
to "
and it is in this
sense
that the word is
most
1. Cowie, A. T., Folley, S. J., Cross, B. A., Harris, G. W., Jacobsohn, D., Richardson, K. C. Nature, Lond. 1951, 168, 421. 2. Folley, S. J. Brit. med. Bull. 1947, 5, 142.
*
*
I remember having a conversation some 25 years ago with a Cornishman who thought his county was not particularly beautiful (as well he might for he lived in Bodmin) ; but he added, " There is nothing to beat a I thought of him again as I picked Cornish lane." blackberries from one this summer. The myriad of stones which form the walls are there, I suppose, because it was the easiest way of stacking them when they were taken from the fields, which would certainly be unproductive if they remained there. Nine tiers of stones ; a span each is a usual formation, and, as each stone is often less than an inch broad, in some places there must be over 3000 stones to a yard, and double that for both sides. The loose earth between the stones nourishes a profusion of wild flowers, the gorse with its prickly stalk and bright yellow flower, and the red heather standing erect, the wild poppy, mustard, toadflax, scabious, bladder-campion, knapweed, tansy, and lady’s bedstraw sticking their heads sideways, with their yellow, purple, red, and green shades which would make a lovely design for a carpet. Perhaps a yard away, ferns grow in abundance in every shade of green, and, lastly, thyme with its delicate pink and delectable smell. I have put it last, not because it is the smallest but because it might perhaps go unnoticed if it had no scent. Did Shakespeare put it first because his sense of smell made him notice the bank, and then his roving, observant eye picked out the others ? Picking blackberries in a Cornish lane from the top of a bank which they shared with blue sloes and scarlet hawthorn berries made me realise how truly Bacon wrote when he said, " God Almighty first planted a garden." Wilderness still has its charm. * * * Our Peripatetic Parliamentary correspondent writes : In the passage by the House of the second reading of the National Health Service (D.D.) Amendment Bill as an agreed measure, an important step has been taken to close a gap in our system of social security. In moving its adoption, the Minister of Agriculture and Fisheries said he was proud to be associated with a measure which would provide every type of health care for the Darling Doggies. It had long been felt anomalous that in this country, which had pioneered so many social advances and which abounded in D.D.-lovers, the welfare of our four-footed friends still depended as much on private and voluntary effort as in the days of Gellert and Hodge. (A hon. member : Hodge was a cat.) He apologised, Crichel had rather got him Down, he should have said Flush. All kennels in the country, with the exception of disclaimed dog-baskets, would be administered from the Appointed Day by regional, group, and local kennel boards and committees. In view of the importance of nutrition to health, bones would be provided free of charge or at cost price through the maternal and puppy welfare clinics. Thanks to his friends the bloodhounds, no inroads would be made on the existing transfusion services. He hoped that the day had dawned when the phrase " a dog’s life " would take on a new meaning, and he felt sure that hon. members of all parties would metaphorically lift their hands-he had nearly said * legs-in support. * * From the Anglo-Saxon Chronicle for the
year A.D. 1086-" It very severe year, and a very sorrowful year in England ; and corn and crops were checked, and there was such great misfortune with the weather as cannot easily he conceived. There were such big thunderstorms and such lightning, so that many people were killed, and it kept getting worse and worse among the people, more and more so. May God Almighty make things better." was a
Letters
to
the Editor
LUMBAR PUNCTURE IN POLIOMYELITIS
SIR,—Your correspondents deprecating the perform. of lumbar puncture in cases of poliomyelitis seem
ance
to have allowed their enthusiasm to outrun their dis. means let us dispense with lumbar paralysis has occurred and the diagnosis is certain, though one may still be deceived by the occasional Gruillain-Barre in which sensory signs are minimal
cretion.
puncture
By
all
when
not looked for. But in so-called abortive poliomyelitis the situation is very different. Briefly, in this country at the present time, a patient presenting with acute neck and back stiffness usually has : (1) poliomyelitis ; (2) incipient meningitis (coccal, bacterial, or leptospiral) ; (3) any of the other viral meningo-encephalitides (including perhaps glandular fever and erythema multiforme) ; or (4) subarachnoid haemorrhage. What is one to do then ? Is it suggested that one should wait, thereby wasting precious, and it might well be vital, time until some unmistakable clinical development forces one’s hand ; or attempt by means of lumbar puncture to make a differential diagnosis at onceThe latter is the course which, in my view, one is bound, in the patient’s interest, to follow. (Incidentally, if the waiting policy were widely adopted, subarachnoid haemorrhage might rarely be diagnosed during life.) In any event the large number of cases of nonparalytic poliomyelitis that come into hospital, undergo lumbar puncture, and depart unscathed must surely suggest that the occasions when puncture precipitates paralysis must be exceedingly few. Moreover, the large measure of common agreement between the ratio of non-paralytic to paralytic cases in outbreaks all over the world again suggests that puncture can have no very decisive influence. in altering the balance. The question was debated briefly at the first poliomyelitis conference held in New York in 1948, when the majority opinion ran counter to your correspondents’ views. Finally, are we not becoming a little too " poliomyelitis At this hospital, in striking contrast to conscious " ’? previous years, we have had only one case "of paralytic poliomyelitis since January. Two " bulbars proved to be examples of Guillain-Barré syndrome. Moreover, the " majority of the " abortives would seem to have been mumps, as shown by subsequent clinical developments, or suggested by the findings in the fluid, complementfixation tests, and/or a significant rise in the serum or
amylase. I must apologise for stressing the obvious but it would be intolerable if your correspondents’ contention-that it is bad practice to do a lumbar puncture in cases of suspected poliomyelitis—were to be generally accepted and perhaps subsequently quoted against us in courts of law. South Middlesex Hospital, E. Isleworth. Islewortli.
G. E. BREEN. BREED.
SIR,—Your correspondents are to be supported in their views that undue interference and disturbance in dealing with the poliomyelitis patient in the preparalytic stages of the disease is to be deprecated, and that lumbar puncture in the case where diagnosis is without doubt should best be omitted. I know of no statistical evidence, however, to support the theory that lumbar puncture is a factor precipitating paralysis, and, indeed, experience in this hospital has never given rise to any suspicion of such a reaction. There have been a great many instances where the operation was performed in non-paralytic cases in the meningeal phase and where no paralysis followed. The unpredictable nature of this disease must make untenable any argument that where paralysis followed or increased the cause must be the lumbar
493 it must be as logical to attempt where patients with clinical evidence of accept that, received antiserum and did not neutralising poliomyelitis develop paralysis, this happy state must be attributed to the serum. Those of us with diagnostic units have much opportunity to observe the diseases admitted as suspected poliomyelitis and know only too well how common it is to meet cases with a meningeal reaction clinically indistinguishable from the preparalytic phase of that disease. The information gained from a diagnostic puncture has been invaluable in allowing early and life-saving treatment to begin in many cases of tuberculous and septic meningitis. Conservatism, as advocated by your correspondents, will almost certainly lead to many tragedies. Dr. Albury advocates " specialists " for lumbar puncture. This is obviously impracticable. The operation of lumbar puncture can be efficiently performed with minimal trauma or discomfort by those who have been instructed in the correct technique and have the right eoumment.
puncture.
As
a
corollary,
to
The Western Hospital,
London, S.W.6.
W. HOWLETT KELLEHER
DRUGS THROUGH THE LETTER BOX a household containing two doctors, we are inundated with medical advertisements. As the letters drop on the doormat, they are pounced on by the children, to be distributed to their owners. All advertisements are counted as the children’s " spoil," to be used for cutting out or learning their letters. We find this a satisfactory arrangement and only occasionally salvage a blotter, as we need one. Sometimes this peaceful state of affairs is disrupted by the arrival of samples of drugs by letter post. We have trained the 31f2-year-olds never to open packets of pills or to taste any, so they obediently hand them to us and watch wonderingly while we flush them down the lavatory. Now that our youngest is crawling, the problem has struck us again with renewed strength and we are driven to ask if nothing can be done about what is, in effect, a recurrent peril to medical households with children. Could not all drug manufacturers agree to send a card, to be returned by those who require samples ? Or will it be necessary to press for legislation to prevent the mailing of dangerous drugs to unwilling recipients? SUSANNA ISAACS. London, N.3.
SIR,-As
THE HUMALACTOR
I reply to Dr. Waller’s comments (Aug. 21) the humalactor’? I start with a disclaimer : this invention, called by Dr. Waller" Dr. Gunther’s contraption," is in no way mine and I have no connection with it whatsoever beyond trying it out and finding it useful. Medical inventions of all kinds—drugs, devices, and methods of management—deserve dispassionate appraisal and this I had sought to provide for the humalactor in my brief article on its use. Dr. Waller does not like the humalactor and sees in it a deterrent to the training of midwives and mothers in the technique of manual expression of breast secretion. No-one should fail to recognise the great contributions Dr. Waller has made to understanding the nursing mother and the processes of breastfeeding ; yet, while paying tribute to all he has done and to Dr. Waller himself, with the affection and respect which years of friendship have strengthened, I have thought it right to try other methods. Hospitals differ in their resources in personnel and also in the cases they receive. Many women find manual expression repugnant and, certainly, some nurses should not be taught, neither should they practise, manual expression on mothers in the early puerperium, when breasts are so tender and easily injured. Our mastitis rate has, in fact, risen on
SiR,-May
on
each of the four occasions when we have introduced Because of thie frequent early manual expression. failure and because early engorgement causes much suffering, alternative methods shortly to be described are used to reduce the incidence of engorgement of the breasts in this hospital-hence the relative smallness of the volumes of surplus milk removed by the humalactor. The severest censure in Dr. Waller’s letter is that reliance on a machine will render midwives and doctors content to let the patients manage as best they can when they go home. To me this is an illogical conclusion and an unjustifiable charge. Midwives .are not made more considerate by being driven to perform hurtful practices on difficult and engorged breasts, nor does recognition of the tenderness of breasts in the first week prevent a nurse or doctor from providing mothers with means to empty their breasts if necessary later. We find that if engorgement is avoided and if the department does not glory in the numerical pride of excess milk, most mothere go home contentedly and adequately feeding their babies and seldom have to do more than keep a watchful eye for excess secretion. Nor are failures as common as Dr. Waller’s reckoning would suggest : the humalactor, when we had only one machine, was used on those who had difficulties. At present we try to teach mothers the skill of manual expression before delivery and rely on the method where we deem necessary, but not, if we can help it, before the fifth day. The humalactor’s characteristics seemed worth describing since they differ happily from those of all other breast-pumps I know. I would agree with Dr. Waller’s matron that these others can stay unrepaired, or, where I have so often seen and leftthem, "lost" in a cupboard. Obstetric Hospital, University College Hospital, London, W.C.1.
MAVIS GUNTHER.
TERMINOLOGY IN LACTATIONAL PHYSIOLOGY
SIR,—On Sept. 7, the British Association is to hold a session of its agriculture and physiology sections,
joint
and the subject has been announced as The Physiology of Milk Liberation. The discussion will deal with the reflex which causes movements of milk from secretory alveoli in which it is stored to duct spaces near the teat, which occurs when the baby animal feeds and which is known as the draught reflex in women and as the let-down in cows. We think that the new term, liberation," is an unsuitable word for this process, for it suggests that the milk is held back and then released, and the term brings to mind a relaxation of a sphincter or the escape of the secretion across a membrane. We think the term ejection," introduced in a valuable extension1 of Folley’s excellent scheme2 setting out the phases of lactation, is also unsuitable, because milk is but rarely ejected, although the pressure within the duct is increased by the reflex. The same consideration applies to the term "
"
"
expulsion." Propulsion " "
seems to us to be preferable to any other of the terms so far suggested, for it connotes an active transportion of milk, it is without misleading implications, and it is widely used in the practice of human lactation. We think its general acceptance would make for easier understanding by those coming to know for the first time of the movement of milk in the
breast
or
mammary
gland.
We take this opportunity of
protesting strongly against suggestion of Cowie et al.l that in lactational physiology the verb " to suckle " should be used for what the baby animal does to get milk from the mamma—and for nothing else. To suckle means (o.E.D.) to "give suck the
to "
and it is in this
sense
that the word is
most
1. Cowie, A. T., Folley, S. J., Cross, B. A., Harris, G. W., Jacobsohn, D., Richardson, K. C. Nature, Lond. 1951, 168, 421. 2. Folley, S. J. Brit. med. Bull. 1947, 5, 142.