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MEMORIAL TO DR. PARKIN OF MALTON
1353
CORRESPONDENCE MEMORIAL TO DR. PARKIN OF MALTON To the Editor of THE LANCET of the outbreak of typhoid fever in Malton, Yorks, which culminated in the death of Dr. George C. Parkin, who contracted typhoid fever and died on Dec. 3rd, after exhausting his reserves of strength by continual and unsparing attendance on the victims. Dr. Parkin, who was only 31 years of age, leaves a widow, a son 2 years old, and an unborn child. He made such provision for them as he could afford, but, cut off in the beginning of his career, he was unable to provide for the education of his children. We wish to raise a fund to be devoted to this purpose as a memorial to the heroic sacrifice he made in the cause of others. We who worked with Dr. Parkin and admired his devotion to duty and great ability do earnestly commend this appeal to all who are able to help. Contributions may be sent to Mr. James Crooks, F.R.C.S., at the Hospital for Sick Children, Great Ormond-street, London, W.C. 1. We are, Sir, yours faithfully, H. A. T. FAIRBANK,
SIR,-Your readers
are aware
thick for Sick Consulting Surgeon to the Hospital for W.C.I. Children, Great Ormond-street, W.C.1.
JOSEPH W. LEECH, Consulting Surgeon to the Royal Victoria Infirmary, Newcastle-on-Tyne. Now3astle-on-Tyn,-. W. T. GORDON PUGH, Med. Supt., Queen Mary’s Hospital for Dec. llth, 1932. 932. Children, Carshalton, Surrey.
SERUM TREATMENT OF POLIOMYELITIS To the Editor
of THE
LANCET
SIR,-In leading article in your issue of Nov. 12th you refer to results of serum therapy in poliomyelitis reported by Dr. F. G. Morgan and myself. Our Melbourne results are criticised on the ground that minor cases of poliomyelitis, which in the absence of public interest would not have sought medical attention, were included in the treated series. I would refer the critics to the case-histories in the report’the symptoms, cerebro-spinal fluid findings, and the policy adopted in Victoria in the selection of cases for serum therapy. While it is admitted that public interest during the epidemic of 1931 brought many cases of minor illness to medical attention, they were not treated with serum unless, while under observation, definite indications for lumbar puncture developed and the fluid findings confirmed the clinical suspicion. " It has been strongly emphasised that even in time of epidemics, in the absence of definite indication, lumbar puncture for diagnostic purposes, in cases of acute illness, is not justifiable ; but every patient suffering from an acute illness, for which definite cause cannot be found by careful clinical examination, should be carefully watched and a
re-examined in order to detect the first evidence of meningeal involvement when one still has time to confirm the diagnosis by examination of the fluid and to administer serum."
frequently
This
policy, laid down in 1925, was faithfully adhered during the six years of work in Victoria for two reasons : (1) serum supplies were not large enough to allow treatment on suspicion, if the doses considered adequate were to be available for proven cases ; (2) the opinion was held in Victoria that lumbar puncture in the preparalytic stage is not a procedure to be lightly undertaken. This opinion is not held generally in New York City. Dr. Josephine Neal, to
1
THE
LANCET, 1932, i., 469 and 527.
who is in
charge of the meningitis division of the City Diagnostic Laboratories, recommends the procedure.2Discussion of case records with Dr. Neal has shown me that cases would be submitted to lumbar puncture in New York which in Victoria would be kept under observation for the development of further indications for the procedure, even though they had been incontact with a patient with paralysis. Many of the patients in whom the spine sign and cerebro-spinal fluid changes are present develop immunity for themselves and recover before little or any serious damage has been done to the nervecells. In others, development of immunity is delayed until after widespread damage has occurred. Unfortunately, as pointed out by W. L. Aycock,3 no test is. available to the clinician caring for a patient in the preparalytic stage, by which he may foretell in which group his patient may be placed. As questioned by S. Flexner,4may not the " mechanisms in man tending to abort and confine the virus infection be" supplemented and fortified by convalescent serum when " the severe form of the experimental disease can be prevented or mitigated by means of immune serum " May not the injection of a large amount of immune serum confer a passive immunity to inhibit. the action of virus until the development of active immunity has occurred ? The Victorian studies were undertaken in this spirit of inquiry. The fact that of 76 cases treated with. serum in the epidemic of 1930-31, none died and only 4 were affected by paralysis of the degrees of poor, trace, or absent (Harvard Infantile Paralysis Commission Standards), only 2 of whom are likely to have residual crippling, justified the clinical impression that the serum then available was effective in protecting from severe damage any patients slow to develop immunity for themselves. This impression was deepened by the observation that in the four failures deviations occurred from the usual policy of administering a second dose if the response to the first had not been satisfactory. The writer of your leading article is inaccurate in stating " Macnamara and Morgan give an average. dose of about 60 c.cm. intrathecally at first." Study of the case records reported will show that the largest dose given intrathecally was 30 c.cm., though the largest total dose, given partly intrathecally and partly intravenously at the first injection, was 120 c.cm., while the largest total dose given to any patient, was 190 c.cm. Because it was appreciated that different batches of serum vary in potency and that the urgency of the condition varies in different patients, no attempt was made to adopt an arbitrary dosage, but to give enough serum to produce the desired effect : lowering of the temperature and improvement of the general condition. If it is necessary in England to use the serum of persons with paralysis of long duration, larger doses may be necessary than those found effective in Victoria. I cannot agree with the writer of your article that because M. Brodie in Montreal found that the serum of 76 per cent. of 29 apparently normal persons had definite protective properties against the Flexner mixed virus of poliomyelitis, one may deduce from this that serum of normal adults throughout England is as effective as that of paralysed persons against the virus in England this year. The work of W. L. 2
Poliomyelitis, Baltimore, 1932, p. 224.
3 Jour. Amer. Med. Assoc., Sept. 24th, 1932. 4 Ibid., 1932, xcix., 70.
CORRESPONDENCE MEMORIAL TO DR. PARKIN OF MALTON To the Editor of THE LANCET of the outbreak of typhoid fever in Malton, Yorks, which culminated in the death of Dr. George C. Parkin, who contracted typhoid fever and died on Dec. 3rd, after exhausting his reserves of strength by continual and unsparing attendance on the victims. Dr. Parkin, who was only 31 years of age, leaves a widow, a son 2 years old, and an unborn child. He made such provision for them as he could afford, but, cut off in the beginning of his career, he was unable to provide for the education of his children. We wish to raise a fund to be devoted to this purpose as a memorial to the heroic sacrifice he made in the cause of others. We who worked with Dr. Parkin and admired his devotion to duty and great ability do earnestly commend this appeal to all who are able to help. Contributions may be sent to Mr. James Crooks, F.R.C.S., at the Hospital for Sick Children, Great Ormond-street, London, W.C. 1. We are, Sir, yours faithfully, H. A. T. FAIRBANK,
SIR,-Your readers
are aware
thick for Sick Consulting Surgeon to the Hospital for W.C.I. Children, Great Ormond-street, W.C.1.
JOSEPH W. LEECH, Consulting Surgeon to the Royal Victoria Infirmary, Newcastle-on-Tyne. Now3astle-on-Tyn,-. W. T. GORDON PUGH, Med. Supt., Queen Mary’s Hospital for Dec. llth, 1932. 932. Children, Carshalton, Surrey.
SERUM TREATMENT OF POLIOMYELITIS To the Editor
of THE
LANCET
SIR,-In leading article in your issue of Nov. 12th you refer to results of serum therapy in poliomyelitis reported by Dr. F. G. Morgan and myself. Our Melbourne results are criticised on the ground that minor cases of poliomyelitis, which in the absence of public interest would not have sought medical attention, were included in the treated series. I would refer the critics to the case-histories in the report’the symptoms, cerebro-spinal fluid findings, and the policy adopted in Victoria in the selection of cases for serum therapy. While it is admitted that public interest during the epidemic of 1931 brought many cases of minor illness to medical attention, they were not treated with serum unless, while under observation, definite indications for lumbar puncture developed and the fluid findings confirmed the clinical suspicion. " It has been strongly emphasised that even in time of epidemics, in the absence of definite indication, lumbar puncture for diagnostic purposes, in cases of acute illness, is not justifiable ; but every patient suffering from an acute illness, for which definite cause cannot be found by careful clinical examination, should be carefully watched and a
re-examined in order to detect the first evidence of meningeal involvement when one still has time to confirm the diagnosis by examination of the fluid and to administer serum."
frequently
This
policy, laid down in 1925, was faithfully adhered during the six years of work in Victoria for two reasons : (1) serum supplies were not large enough to allow treatment on suspicion, if the doses considered adequate were to be available for proven cases ; (2) the opinion was held in Victoria that lumbar puncture in the preparalytic stage is not a procedure to be lightly undertaken. This opinion is not held generally in New York City. Dr. Josephine Neal, to
1
THE
LANCET, 1932, i., 469 and 527.
who is in
charge of the meningitis division of the City Diagnostic Laboratories, recommends the procedure.2Discussion of case records with Dr. Neal has shown me that cases would be submitted to lumbar puncture in New York which in Victoria would be kept under observation for the development of further indications for the procedure, even though they had been incontact with a patient with paralysis. Many of the patients in whom the spine sign and cerebro-spinal fluid changes are present develop immunity for themselves and recover before little or any serious damage has been done to the nervecells. In others, development of immunity is delayed until after widespread damage has occurred. Unfortunately, as pointed out by W. L. Aycock,3 no test is. available to the clinician caring for a patient in the preparalytic stage, by which he may foretell in which group his patient may be placed. As questioned by S. Flexner,4may not the " mechanisms in man tending to abort and confine the virus infection be" supplemented and fortified by convalescent serum when " the severe form of the experimental disease can be prevented or mitigated by means of immune serum " May not the injection of a large amount of immune serum confer a passive immunity to inhibit. the action of virus until the development of active immunity has occurred ? The Victorian studies were undertaken in this spirit of inquiry. The fact that of 76 cases treated with. serum in the epidemic of 1930-31, none died and only 4 were affected by paralysis of the degrees of poor, trace, or absent (Harvard Infantile Paralysis Commission Standards), only 2 of whom are likely to have residual crippling, justified the clinical impression that the serum then available was effective in protecting from severe damage any patients slow to develop immunity for themselves. This impression was deepened by the observation that in the four failures deviations occurred from the usual policy of administering a second dose if the response to the first had not been satisfactory. The writer of your leading article is inaccurate in stating " Macnamara and Morgan give an average. dose of about 60 c.cm. intrathecally at first." Study of the case records reported will show that the largest dose given intrathecally was 30 c.cm., though the largest total dose, given partly intrathecally and partly intravenously at the first injection, was 120 c.cm., while the largest total dose given to any patient, was 190 c.cm. Because it was appreciated that different batches of serum vary in potency and that the urgency of the condition varies in different patients, no attempt was made to adopt an arbitrary dosage, but to give enough serum to produce the desired effect : lowering of the temperature and improvement of the general condition. If it is necessary in England to use the serum of persons with paralysis of long duration, larger doses may be necessary than those found effective in Victoria. I cannot agree with the writer of your article that because M. Brodie in Montreal found that the serum of 76 per cent. of 29 apparently normal persons had definite protective properties against the Flexner mixed virus of poliomyelitis, one may deduce from this that serum of normal adults throughout England is as effective as that of paralysed persons against the virus in England this year. The work of W. L. 2
Poliomyelitis, Baltimore, 1932, p. 224.
3 Jour. Amer. Med. Assoc., Sept. 24th, 1932. 4 Ibid., 1932, xcix., 70.