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another 2. But even with such patients success may bedeceptive. In cold weather chilblains deteriorate ;when milder weather sets in they heal. I have thereforeregarded as successful only those cases which improvedduring a period of cold weather. As the temperatureswere low from the middle of January up to the end ofFebruary, there were at least 6 weeks of nearly uniformweather conditions in which to make observations. Itried to obtain other evidence of the effect of the treat-ment. In 3 cases only one hand was seriously affectedand the other hand was nearly free from chilblains ; inthese, only the affected side was bandaged. In 2 casesthe chilblains on the treated side improved, whereas theother hand developed large chilblains where only a slightredness had been visible. In the third case, the treatedside did not react at once, but remained unchanged for aweek, at the end of which time the untreated side wasmuch worse than the treated. Continued treatmentbrought definite improvement for both hands. Oint-ments only were used on 2 cases for a week, with onlyvery slight improvement; bandaging was then begunand complete healing followed. In 2 other cases therewas recurrence after the usual initial improvement,which had appeared within a week of the start of treat-ment. It was found, however, that the boys in questionhad applied their bandages too loosely. A few daysafter this had been put right the chilblains disappearedagain.The most impressive result was that most patients

reported a definite improvement in their symptoms afteronly a night or two. Itching and tenseness had gone andpain was less. Externally, no change was visible atthis stage; objective signs of healing could be found onlythree or four days later. In 3 cases the treatment wasnot fully successful. In one success was achieved onlyafter a fortnight, and only by bandaging the arms for 20hours out of 24. In another all fingers of both handswere affected ; during the previous winter they hadulcerated, and long treatment with ointment had beennecessary. This winter, hypersemia was started as soonthe first signs of chilblains became visible ; in spite ofthis they developed, but they did not ulcerate and were -not as large as they had been the year before ; a responsewas achieved only by bandaging the arms for 20 hoursout of 24, and even then healing was slow. The thirdcase showed no clear response to treatment. After abouta fortnight, some improvement was visible, but this mayhave been due to milder weather.The reason for the beneficial effect of this local venous

congestion is not easily understood. Lewis says that thelimb which has been chronically exposed to cold reactswith vasodilatation, caused probably by the liberationof a vasodilating substance, and its temperature falls.This fall of temperature suggests that the circulation inthe superficial capillary blood spaces is slowed downso much that it nears complete stagnation. Passivehyperaemia also leads to stagnation, but here the arterialinflow is unhindered, and only the outflow slightly im-peded. More blood is thus forced into the limb andmoved slowly through it. This movement is going onunder an increased vis a tergo, and it seems reasonableto suppose that this mechanism forces blood through allpotential blood spaces in the limb, including the capillaryspaces dilated (and paralysed) by cold, thus reopening thecirculation through them.

This tentative explanation is supported by the factthat passive congestion slightly raises the temperatureof a limb, indicating a good circulation. If, however, thebandage is applied too firmly and the outflow restrictedtoo much, the limb becomes cold and the congestion hasno curative effect. Here the greater stagnation iscomparable to that produced by local cold.

SUMMARY

Peripheral venous congestion by Bier’s method wasused as treatment for chilblains. Out of 24 patients 21were treated successfully.

Bl APPOINTMENTS.—Since August the movements of holdersof Bl posts have been controlled by the Minister of Health(see Lancet, 1942, ii, 233). This restriction was establishedin the first instance for three months, but it has now beendecided to continue it until the end of January.

AN UNUSUAL MENINGOCOCCALRELAPSE SYNDROME

A. B. CHRISTIE, M D ABERD, D P HMEDICAL SUPERINTENDENT, BOROUGH SANATORIUM FOR INFECTIOUS

DISEASES, SOUTHEND-ON-SEA

TRUE meningitic relapses after attacks of meningo-coccal meningitis, though uncommon, have been reportedfrom time to time ; chronic meningococcal septicaemia,is a syndrome that has of late become relatively familiar..The unusual feature in the first of the following two casesis the occurrence, several months after an attack of acutemeningococcal meningitis, of chronic meningococcalsepticaemia associated with a frankly purulent cerebro-spinal fluid in a patient who showed no signs of menin-gitis and was in fact comparatively well and able to be upand about. The second case, in which the fluid hasremained abnormal for several months after clinical cure,is cited as a commentary on the possible pathogenesis ofthe first.

CASE-HISTORIES

CASE 1.—I saw the patient, a man of 40, at his home onFeb. 7, 1941, with moderately severe meningococcal meningi-tis ; he had been ill two days. He was mentally confused,apathetic and incontinent of urine. Neck rigidity was com-plete, Kernig’s sign was strongly positi-ve, and there was ascanty but typical purpuric rash on chin, back and limbs.On admission to the sanatorium, his CSF was turbid;meningococci were seen in the stained fibn. He was given2 g. of sodium sulphathiazole and 20 c.cm. of polyvalentmeningococcal antitoxin intravenously ; 4 hours later, 2 g. ofsulphapyridine by mouth and thereafter 1 g. 4-hourly to atotal of 25 g. Owing to short supplies it was not possible tocontinue sulphathiazole treatment.He responded rapidly and by the 6th day seemed normal;

treatment was stopped. He was allowed up on the 13th dayand discharged on the 21st. Two swabs of the nasopharynxwere negative before his discharge, but he was not lumbarpunctured because it was not then my custom to do thisexcept for diagnostic or therapeutic reasons.Towards the beginning of July, 1941, he called at the hos-

pital saying he felt his meningitis was returning. He didnot feel fit for his work as an auxiliary foreman ; he hadrepeated attacks of coldness when all he could do Was tosit in the post feeling miserable. He had been rather pleasedthat his original illness was a serious one, so I-did not regardhis complaints very seriously, but I examined him carefully,in the hope of reassuring him. I found nothing abnormal,no signs of meningitis ; fundi were normal and blood Wasser-mann reaction was negative, but I did not do a lumbarpuncture. On July 26 I was called to his house. He was inbed complaining of intense headache and shivering; histemperature was 103° F. and his trunk and limbs were

TABLE I

covered with a faint pink macular rash; Kernig’s sign wasnegative and there was no trace of neck rigidity or any other,abnormal sign in the central nervous system. The intenseheadache was obviously feigned, but he was alarmed abouthis condition. I admitted him to hospital as a probable caseof chronic meningococcal septicaemia; on admission theheadache vanished and the temperature fell in half an hour ;blood-culture was therefore not done. For the next few dayshis temperature fluctuated though he had no physical signs.On July 30 blood was taken for culture, agglutination tests

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for abortus fever, and film for malaria ; all proved negative.On July 31 his temperature was 100° F. ; lumbar puncture’released thick, frankly purulent fluid. A fine macular rashhad again developed. Treatment with sulphapyridine. 1 g.4-hourly, was begun but next day hearing that blood-culturewas negative, I stopped treatment for 12 hours, and repeatedthe blood-culture, which was again negative. Treatment wasresumed with sulphathiazole, on the theory that the organismmight have become sulphapyridine-fast. On Aug. 2 the CSFwas much clearer, in spite of the small dosage of sulphonamides(4 g. of sulphapyridine and 4 g. of sulphathiazole). Sulpha-thiazole was continued, 1 g. 4-hourly, to a total of 32 g.On Aug. 14 the CSF was clear ; and the patient was dis-charged on Aug. 21 with instructions to report periodically.CSF findings were as shown in table i.CASE 2.-On Nov. 2, 1941, a boy of 15 was admitted with

moderately severe meningococcal meningitis. CSF straw-coloured ; meningococci present. He received in 6 days atotal of 33 g. of sulphapyridine and improved rapidly. OnNov. 14 he was ready for discharge, as far as his physicalcondition went, but his CSF still showed 55 cells per c.mm.He was accordingly given a second course of 30 g. sulphapyri-dine. On Nov. 21 there were still 12 cells per c.mm presentand protein was 100 mg. per 100 c.cm., but it was impractic-able to keep him longer in hospital. He has reportedperiodically for examination: particulars of his CSF are asgiven in table 11.

TABLE 11

sm. lym. = small lymphocytes.

Pressure was increased at every lumbar puncture. He hasremained well except for a fortnight towards the end ofJanuary, 1942, when he suffered from recurrent headaches.In view of my experience with the first case, he is being keptunder observation, although it is recognised that a slowreturn to a normal CSF after acute meningitis is notuncommon.

DISCUSSION

Although cultures of blood and CSF were both nega-tive in the first case on the occasion of his relapse, the- initial attack in February, 1941, was confirmed bacterio-logically and there can be little doubt that the case wasone of chronic meningococcal septicaemia, possiblyoriginating and being fed from a focus of infection in thespinal canal. Whether the CSF ever returned to normalafter the original infection, and how long the patientwent about with pus in his canal, is unknown ; but it islikely that at least 3 weeks before his second admissionand probably for longer he was suffering from repeatedmild attacks of meningococcal septicaemia. The moststriking point clinically was the presence of a purulentCSF and the complete absence of any neurological sign.From the therapeutic point of view, the danger of relyingon clinical appearances in assessing cure in cases ofmeningococcal meningitis becomes apparent.

SUMMARY

Two cases of meningococcal meningitis are described.In the first several months after the initial attack chronicmeningococcal septicaemia developed, associated withpurulent CSF unaccompanied by neurological signs. Inthe second case after the initial attack the CSF has re-mained abnormal but apart from some headache therehave been no recognisable symptoms. Both cases

emphasise the importance of verifying apparent clinicalcure by lumbar puncture. The first case indicates thatsulphapyridine may produce complete apparent clinicalcure without sterilising the CSF.

I wish to thank the medical officer of health for Southend-on-Sea for permission to publish this case; and Dr. H. B. May ofthe Emergency Pathological Service for the bacteriologicalreports.

DIPHTHERIA IMMUNISATION IN ENGLANDAND WALES

A STATISTICAL STUDY OF THE REACTIONS AND

DIFFICULTIES OF MOTHERS

BY THE COMMITTEE FOR THE STUDY OF SOCIAL MEDICINE

ACCORDING to a Ministry of Healthl estimate the pro-portion of children immunised in England and Wales isat least a third. Since, however, the child populationwill not be adequately protected against diphtheria, inthe official view, until at least 3 out of every 4 childrenare immunised, it is obvious that the response by parentsto the scheme for immunisation has far from reachedexpectations, in spite of the varied media of propagandaand education employed. In view of this, the Ministryof Health 2 has recently initiated a new campaign.The object of the present inquiry, a sample investiga-

tion carried out from September, 1941, to May, 1942, wasto determine some of the major reasons for the compara-tively poor response to the immunisation scheme, takingEngland and Wales as a whole, in order that the mostefficient and economical improvements might be recom-mended by the committee. The mother was made thefocal point of the inquiry, and her reactions, objectionsand difficulties connected with the scheme were analysed.

METHODS OF INQUIRYTo obtain a balanced sample of the total population

of mothers, 25 localities were chosen so as to cover thegreater part of the country, and also so as to includetowns in different size-groups, as well as reception,evacuation and neutral areas.3 As the most convenientway of interviewing mothers by skilled personnel, thelady almoner of a leading hospital in each locality wasasked to obtain the required information, and the successof the inquiry was largely due to the excellent coöpera-tion given. Each almoner was sent 100 or 200 question-naire forms, the number depending on the size of thelocality chosen, to be filled in for the first 100 or 200mothers, having any children under 14 years old whoentered her office-whether because of their own illness,or on a visit to patients, or for any other reason. In thisway a random sample of mothers of children under 14attending these hospitals was obtained. Although thesample is weighted in favour of urban areas and ofworking-class families, it is these which contain the bulkof the population at risk.The age-composition of the total number of children

of these mothers was compared with that estimated forthe whole of England and Wales for the year 19424; thedifferences were found to be statistically insignificant.The total number of mothers covered by the sample was3930, and the number of children under 14 years 7596.The main questions asked each mother were :

1. Whether she had heard of the scheme for the immunisa-tion of children against diphtheria.

2. If she had heard, the source of her knowledge of thescheme.

3. For each child under 14 years (a) age ; (b) whetherimmunised ; (c) age when immunised.5

4. If not all of her children of " immunisable age "

(i.e.,over 1 year) had been immunised, the reason for this omission.

1. Circular 2627, April, 1942.2. Circular 2677, July, 1942.3. The 25 localities and hospitals from which data were collected

are as follows: London, North (Royal Northern Hospital),West (Hammersmith Hospital) and West Centra] (UniversityCollege Hospital); Manchester (Northern Hospital); Liver-pool (Royal Infirmary); Leeds (General Infirmary) ; Sheffield(City General Hospital); Bristol (General Hospital); New-castle (Royal Victoria Infirmary) ; Hull (Royal Infirmary) ;Cardiff (Llandough Hospital); Leicester (Royal Infirmary) ;Nottingham (General Hospital) ; Stoke-on-Trent (NorthStaffs Royal Infirmary); York (County Hospital); WestBromwich (West Bromwich and District General Hospital) ;Carlisle (Cumberland Infirmary) ; Oxford (Radcliffe Infir-mary); Uxbridge (Hillingdon County Hospital); Bedford (BedsCounty Hospital); Harrogate (Harrogate and District GeneralHospital) ; Tunbridge Wells (Kent and Sussex Hospital);Rochester (Hospital of St. Bartholomew); Penzance (WestCornwall Hospital); Chelmsford (Chelmsford and EssexHospital).

4. Dr. Enid Charles’s " moderate assumption " in Special Memoran-dum No. 40, of the London and Cambridge Economic Service.

5. Information under heading (c) has not so far been analysed.