Poliomyelitis: A note on treatment

PUBLIC HEALTH

AUGUST

in persons who took up residence in Harrogate after the onset of the epidemic; thus the introduction of fresh susceptibles into the town during the outbreak does not appear to have played any major part in the maintenance of the epidemic. Coneludon

(1) A brief outline of the history and epidemiology of acute poliomyelitis has been given with special reference to the Harrogate epidemic in 1940. (2) An account of the outbreak is given, together with the steps t~ken to secure suitable hospital accommodation for the patients. (3) Special mention is made of cases arising in a secondary day-school and in a private day- and boarding-school, and also of the occurrence of secondary cases in the same household. (4) A few details are given of the clinical character of the outbreak, together with a tentative estimate of the residual results in cases affected by the disease. Finally I would express my warmest thanks to the medical staff of the Harrogate General Hospital for their willin~ and ready co-operation and also to the Regional Office of the Ministry of Health, which constantly advised and assisted me in dealing with this outbreak. REFERENCES

BURNET,F. M. (1940.) Med. 1. Austral., March 9th, 1.

K~MI'F, J. E., and SOULE, M. H. (1940.) Proc. Soc. ex#. Biol., N.Y., 44, 431. LANDSTEINER,et al. (1911.) Ann. Inst. Pasteur, 25. LEPINE, P., SEDALLIAN,P., and SAUTTER,V. (1939.) Bull. Acad. M~d., Paris, 122, 141. LOCKHART. (1837.) Life of Sir Walter Scott, 1, 14. MEDIN. (1890.) Internat. Med. Congress, Berlin. PAUL, J. R., TIIASK,J. D., and GARD,S. (1940.) 1. exp. l$~ed., 71, 765. SMITH. R. E. (1939.) Guy's Hasp. Rep., 89. TRASK, J. D., PAUL,J. R., and VmNEC, A. J. (1940.) 1. exp. Med.. 71, 751. POLIOMYELITIS:

A NOTE

ON

TREATMENT By SINCLAIR MILLER, D.S.O.. M.C., M.D., M.R.C.P., Senior Physician, Duchy House Clinic, Harrogate It is generally accepted that the causative organism of poliomyelitis is a filterable virus and that the portal of entry into the body is probably the nasopharynx, though some authorities maintain the infection can occur via the alimentary tract. After entry the route of spread of the virus in man has not yet been fully demonstrated, the generally accepted opinion being in favour of a strictly neurotropic spread via the olfactory lobes, hypothalamus, mid-brain, and descending neurones. I myself do not subscribe to this method of spread. The sudden onset of the illness, its toxaemia and pyrexia, appear to me to resemble closely the early stages of other recognised acute systemic infections, and post-mortem examinations of fatal cases show evidence to support this. Involvement of the lymphoid tissue is common, including tonsils and spleen as well as the lymph glands. Flexner and Lewis have demonstrated the presence of the virus in human mesenteric lymph glands. I hold that the infection is systemic from the beginning, with, perhaps, some selective affinity of the virus for the anterior horn cells. 214

There are many points in favour of a generalised infection s but space does not allow me to discuss these in further detail. Increased knowledge of the distribution of the virus, with the greater range of experimentation now that certain strains of rats and mice have been shown to be susceptible to the disease, will no doubt throw much light upon the mode of spread of the virus and methods of prevention. Treatment

During the recent outbreak of acute poliomyelitis in Harrogate I had an opportunity of treating a limited number of cases. In papers in the Lancet (Miller and Wray, 1940 and 1941) I have described the use of sulphapyridine given in large doses intravenously combined with intramuscular injections of convalescent poliomyelitis serum. The results were most promising in several cases in which the severity of the attack was such that little hope of survival could be entertained. The following is an example of the response obtained in a series of sixteen cases treated by sutphapyridine and s e r u m : CASE HISTORY A male, aged five years, was seen on the evening o f the fourth day of illness, The child had returned home from school three days before with headache and had been unable to go to school on the following day; he was off food and restless. He was worse on the next day; fever was slight and he passed a very restless night, with repeated attacks of vomiting. On the morning of the fourth day the temperature was 99"6° F. and the child very toxic, but no diagnostic signs were present. Late in the afternoon he became worse, and in the evening the temperature was 102 ° F. ; he was stuporous and irritable, severe frontal headache was present, head retraction was obvious, and there was pain at back of neck. He was unable to support his head when asked to sit up in bed ; there was a moderate amount of paresis of the right arm and left leg ; superficial reflexes were present, the left knee-jerk being very active; Kernig's sign was positive in both legs. Though only five years old, the child was given 1 gramme of sulphapyridine soluble intravenously in 20 c.cm. of saline with 15 c.cm. of convalescent poliomyelitis serum intramuscularly, followed by one sulphapyridine tablet (0.5 gramme) four-hourly and fluids freely. On the next day the child was much better; temperature was 99 ° F., both morning and evening. On the day after this, the temperature became normal and his condition was satisfactory" ; the left knee-jerk was now elicited only with great difficuhy, the right being the same as when first examined. There was no further extension of the paralysis. Further progress was uneventful, the child being left for a time with slight residual weakness of the right arm and left leg. When he was examined two months later it was almost impossible to detect any evidence of residual paralysis and the reflexes had returned. In none of the cases treated with sulphapyridine and serum has there been any serious constitutional upset. A careful watch has been kept on the cytology of the blood and nothing untoward has been noted; there has been little gastric disturbance and the serum gave rise to no reactions. Routine

of Treatment

The following is the routine I am adopting at present: - -

1941 (1) Patients showing malaise or indefinite pyrexia without apparent cause are given sulphapyridine by mouth in appropriate doses and kept under close observation. (2) Patients with earlier manifestations of the infection receive in addition convalescent poliomyelitis serum. Initially, 2 grammes of sulphapyridine by mouth and 20 c.cm. of convalescent serum intra.muscularly are given, and 1 gramme of sulphapyridine is repeated four-hourly until the temperature settles unless there are serious contraindications. Occasionally the serum is repeated once or twice. (3) Patients presenting acute symptoms, where paralysis is impending or has already developed, receive initially 2 or 3 grammes of sulphapyridine soluble in physiological saline intravenously at the earliest moment possible, together with 20 c.cm. of convalescent serum intramuscularly. The sulphapyridine soluble is repeated four-hourly until 8 to 10 grammes have been given. A second dose of 20 c.cm. of the serum is administered eight to ten hours after the first. Next day sulphapyridine soluble and serum are repeated; in the more severe cases further injections are given o11 the third day, but usually they are not required. Modification for children is made according to age. Since this procedure has been adopted we have had 11o serious extension of paralysis in any case, nor" have there been any deaths; such reactions as occurred were negligible.

Award for Gallantry in Civil Defenee The award of the George Medal to Dr. Laura Bateman, Medical Officer, Brook Hospital, Shooter's Hill, is announced in a Supplement to the London Gazette dated June 13th. The announcement reads as follows: " When the Brook Hospital was bombed two maids were imprisoned by debris, Dr. Bateman quickly relieved the suffering of the first maid, but the other was buried under girders and masonry. Dr. Bateman volunteered to crawl under the wreckage and administer an anaesthetic. A porter held her, suspended by her ankles, while she reached the casualty and successfully carried out the injection. A slight subsidence might have resulted in her being trapped and fatally crushed. The danger was very apparent, but this did not deter Dr. Bateman from carrying out a gallant and difficult action." The Minister of Health (Circ. 2407) calls the attention of authorities to the desirability on nutritional grounds of making available to patients and staffs of hospitals within the Emergency Hospital Scheme, and to inmates and staffs of any other residential Institutions under the control of local authorities, bread made of national wheatmeal flour. This flour contains the greater part of the germ of the wheat, with some of the finer bran, but excludes the coarser bran. It thus contains not only most of the vitamin B~ but also most of the remainder of the vitamin B complex, as well as valuable mineral elements which are removed in producing white flour.

PUBLIC HEALTH CORRESPONDENCE DIPHTHERIAIMMUNISATION To the Editor o[ PUBLIC HEALTH SIR,--I have to thank you for your comments (PUBLIC HEALTH, July, 1941, p. 175) on my recent article in the Medical Officer. There are one or two small comments arising out of those remarks which seem worth while. In the first place, is not the Emergency Hospital Laboratory Service a child of the Ministry of Health, and is it a fact that the father advises two injections of A.P.T. of 0'2 c.cm. and 0"5 c.cm., while the rebellious child (to wit, the E.H.L.S.) specifically advises the dosage o.f 0'1 and 0"3 c.cm. of A.P.T.? Is it a case of the right hand not knowing what the left is doing, or is the policy of the Ministry really to countenance the smaller dosage and are the responsible officials hiding behind the petticoats of the E.M.S.? The whole thing savours a little of Dr. Jekyll and Mr. Hyde. The other important point is based on the famous quotation: " T h e evil that men do lives after them. The good is oft interred with their bones." I may be accused of undue anxiety about the ultimate effect on the community of imperfection in the immunisation of individual cases. But in this respect I beg to point out that the failures are shouted from the housetops locally, while all the sound but unknown work which has protected numerous other children passes unrecognised because it is unseen, and because it could never be proved that any of the children concerned would have contracted diphtheria. In the field of diphtheria prophylaxis I object to being classed with the scientists. I imagine that I have been in more intimate contact with more parents than most people in the country in the course of my work, and I know, from peace-time experience, that if we want our clinics to advertise themselves failure must be kept as low as possible. Britons are probably the most thoughtful people on earth when it comes to sizing up the value of anything they are asked to do for their own good. The more we can convince them of the worth of what we are doing, the sooner shall we have the demand for universal immunisation, as opposed to the war-time receptivity of guidance which you so rightly mention is prevalent at the present time. I am hard at work assessing the degree of enormity of the failure of the Ministry (or ought we to say Emergency Hospital Laboratory Service) campaign for the immunisation of our child population. When the facts collected are sufficient, they will be published. In the meantime,, it has reached my ears that some people have thought that something was wrong with Schick toxin because it gave such strongly positive readings after adopting the Jekyll and Hyde dosage of 0"l and 0"3 c.cm. of a certain brand of A.P.T. Would anyone like to say anything about that? Or may I perhaps be right in saying that the Ministry is leading the Nation right up the garden.--I am, etc., GuY BOUSFIELD. London, S.E.5. ]uly 22nd, 1941. 215