Recipient of H.B. Usher to de Montmorency, 13th Dec. 1938.
13 Sep 1939
Description:

‘Dear de Montmorency,

Would you please refer to Rucker’s official letter (Estab. 1026/82.II) of the 23^rd November about the arrangements at Horton Mental Hospital.

We are not contemplating any resistence [sic] to the Ministry’s proposal that these arrangements should continue for the time being, but can you tell me when and how you have it in mind to terminate them? The Ministry’s immediate contact with this particular branch of medical practice and treatment is surely rather unusual?

Yours sincerely,

H.B. Usher.’

[attached to above:

de Montmorency to T. Carnwath, 15^th[?] Dec. 1938.

‘Pl. see Dr. Usher’s letter to me above. I take it your view is that this arrangement should continue permanently (although we have not asked the Treasury for support for more than three years ahead). Perhaps you [would] be so kind as to advise me as to the reply.

H. Usher, 15^th[?].12.38.’

[different hand:

Mr de Montmorency,

Herewith some notes on Horton wh’ may serve your purpose.

It may be suggested that we should charge fees to L[ocal] A[uthorities] and others for the material supplied but I should be loth to do this if it can be avoided. The fees would amount to little treatment would be restructured, and we should be more exposed to attack if any accident occurred and in certain cases this cannot be avoided. At present full responsibility for the treatments rests with MOs in charge of the cases, and we merely suply the material though in fact we do give instruction about the control of the malaria infection.

T.C. 25/1/39.’]

[attached to above:

[T. Carnwath,] Importance of Maintaining the Malaria Therapeutic Unit at Horton.

(A) General Considerations.

Malaria-therapy is now established as the best routine method for the treatment of certain diseases (vide Appendix I.), especially general paresis and other syphilitic affections of the central nervous system. Indeed it appears to be the only economical method by which these types of infection can be treated satisfactorily.

The results of treatment depend largely upon how early the patient receives his course of malaria-therapy. The earlier the cases are treated the more likely are they to become fitted to return to their usual occupations. The later they receive treatment, even although the process of the disease may be stopped, and their mental and physical conditions improved, the less likely are they to recover sufficiently to resume their ordinary avocations, and, as a result, they have to be kept in institutions, often at a very heavy expense to the taxpayer.

Efforts are now being made to bring patients for treatment at a much earlier stage than has been possible in the past. With progress in the knowledge of syphilis it is now possible to select those cases in which the central nervous system is likely to be attacked, and an obvious step forward would be to treat these cases prophylactically at the anti-venereal clinics before serious damage is done.

At present the infective material for malaria-therapy is supplied free by the Ministry of Health, with the purpose of promoting the knowledge and wider use of the method.

(b) The Functions of the Ministry’s Malaria Laboratory.

The functions of the Horton Laboratory are:-

(1) Routine provision of infective material for use in malaria-therapy.

(2) Advice upon malarial and entomological subjects.

(3) Research work.

(4) Educational.

(5) Publicity.

(1). Routine provision of infective material for use in the practice of malaria-therapy is the chief function of the Malaria Laboratory. This is a very highly specialised procedure, and has been perfected after the experiences of 13 years. As is shown in Appendix I., during the past year infective material has been supplied for use in 735 cases. To meet the requirements of different types of patient, it has been found necessary to maintain four different lines of malaria parasite, namely P. vivax, P. malariae, P. falciparum and P. ovale.

To ensure that such material is always available at short notice and that pure strains of the different parasites are maintained, occupies most of the time of the staff. In addition careful records have to be kept of the use to which the material is put and the effects of the treatment in each patient.

Previous to the establishment of the Horton unit clinicians relied mainly for their infective material upon blood obtained from patients having natural infections of malaria. This led to regrettable accidents. Some donor patients, who were apparently only infected with mild forms of parasites (such as P. vivax), had also undetected infections with more virulent ones (such as P. falciparum), with the result that the latter form of infection was also transmitted by the blood inoculation and a certain number of deaths occurred in consequence.

Abandonment of the present system and reliance on infective material from a variety of sources would almost certainly result in a recurrence of serious accidents which would tend to bring the practice of malaria-therapy into disrepute, apart from other objections.

Other countries have also realised the importance of ensuring the distribution of a pure strain of infective material and have established national units for this purpose. Even if it were practicable for local authorities to take over the distribution of malarial material it would still be necessary for the Ministry to exercise close supervision over the purity and type of strain used, and to ensure that the various risks involved in such treatment were guarded against. I do not see how the Ministry could carry out such a function better and more economically than under the present system.

Apart from the question of the purity of the strains, there is also that of the provision of strains which can be depended on to produce suitable, reliable and relatively uniform results.

The pyrogenetic effects of many strains of different species of Plasmodium have been tried at Horton, and their effects upon patients closely studied. It has been found that these strains differ very greatly in their efficiency and practical value. The Madagascar strain of P. vivax now in use at Horton for most routine work, has proved to be so highly satisfactory as compared with other strains of this parasite, that its use is now world-wide.

This strain is maintained in a pure state at Horton, and is distributed freely to clinicians requiring material for malaria-therapy. If the Horton Centre were abolished, or if local authorities had to make their own arrangements, it is highly probable that other less satisfactory or less reliable strains may gradually be taken into use, because of the difficulty in keeping up such strains in a pure state, especially where the number of cases to be treated is small and where facilities for mosquito infection are not available as they are at Horton.

Such an event would probably have a prejudicial effect in the popularity and efficiency of the practice of malaria-therapy in Britain.

The provision of reliable and suitable infective material is a highly specialised business. The routine of this work has taken many years to elaborate and an efficient staff is now available at Horton to carry out the work. It would be extremely difficult or impossible for most local institutions to act as a continuous source of supply or even a single strain of parasite, apart from the difficulties of maintaining the several strains now in use.

The maintenance of these strains at Horton has only been made possible by the cooperation of the Ministry and the London County Council.

As can be seen from Appendix I. the Ministry is now supplying material to about 280 different institutions, and that in many counties only 3 or 4 per cent are treated each year. In such circumstances delegation of the work to local authorities would be not only uneconomical but impractical. For example, the Department of Health for Scotland has tried to make itself independent of Horton by collecting infected blood from patients in different institutions, but apparently without success, for we have periodical requests for material from that Department.

Generally my conclusion is that the need for this work is clamant and I can imagine no more economical way of meeting the need than by the maintenance of the Horton Laboratory.

(2) Advice upon Malarial and Entomological Subjects.

Apart from malaria-therapy many other questions come to the laboratory for disposal.

These have to do mainly with (a) investigation of cases of indigenous malaria and (b) the investigation of mosquito nuisances and their prevention.

These duties require expert knowledge and experience for their performance. The Ministry’s staff at Horton have now a very extended and expert knowledge of this type of investigation. The abolition of the Horton unit would be a serious obstacle to the proper conduct of such investigations in future.

(3) Research Work.

The research work, published by that portion of the staff who are paid directly by the Ministry, is connected mainly with results obtained during the routine work of the laboratory or in attempts to improve upon the methods in use there. During the past two years much work has been done by Lieut.-Colonel Sinton in collaboration with the staff, but this work has been financed mainly by the Royal Society and by the London School of Hygiene and Tropical Medicine and not by the Ministry.

The Laboratory has now an international reputation and supplies and receives research and other material not only from many institutions in the British Isles but also from abroad.

A list of the publications emanating from the Malaria Laboratory during 1938 are given in Appendix II. Nos. 1 and 1a were prepared at the request of the Office International d’Hygiene publique, as there was a demand from workers in different parts of the world for a detailed account of the technical methods in use at the Malaria-Therapy Centre at Horton, upon the model of which many similar centres in other countries, both in Europe and America, had been constructed.

As malaria is now a rare indigenous disease in the British Isles, it might seem that many of these researches deal with subjects having little or no direct relationship to the work of the Ministry of Health, but were rather the function of the India Office or the Colonial Office. However, this work, apart from its scientific interest, is of great national and imperial importance. As is pointed out in the Official History of the Great War, the mass debility from malaria far exceeded the losses from any other disease, and placed a very serious obstacle in the way of the success of the military operations in many war zones. In the event of another war, large masses of troops may have to occupy or fight in malarious areas, and it is essential that we should know as much as possible about the prevention and treatment of this disease.

No other institution has contributed more to our knowledge of this problem than Horton.

In such areas during the last war, the bulk of the invaliding and hospital treatment was due to this disease, and the cost of this and of pensions fell mainly upon the British Exchequer.

It is only by intensive research into all aspects of the malaria problem that one can hope not only to cut down such expenses in future, but also to conserve the man-power and efficiency of such expeditionary forces.

In recent years the backwardness of this country in the production of new chemo-therapeutic agents, as compared with some of the Continental nations, has been emphasised in many quarters, and attempts re being made to remedy this. The Malaria Centre at Horton is one of the few places in England where the value of anti-malarial drugs could be tested on human malaria under conditions of strict scientific control.

At Horton there are now available exceptional facilities for carrying out investigations into malarial problems of world-wide importance under conditions which exist in very few other places in the world.

The present system whereby the laboratory operates in very close collaboration with workers frm the London School of Hygiene and Tropical Medicine, the Royal Society, the London County Council and other organisations, means not only that the Imperial Government is assisting a large amount of research of national importance, at a low cost to itself, but at the same time is in a position to obtain aid in different malaria problems from these sources. The collaboration and cooperation which has been built up around the Malaria-Therapy Centre at Horton would be seriously interfered with if the Malaria Laboratory were abolished.

(4) Educational.

The supply of clinical and laboratory material available at Horton has been taken advantage of by the London School of Hygiene and Tropical Medicine, and other hospitals for teaching purposes. The value of this material and of the experience gained at Horton is recognised by the appointment of Dr. Nicol and Mr. Shute as special lecturers and demonstrators upon different aspects of the problem of malaria.

Workers from many different countries, both in the Empire and abroad, have taken advantage of the special facilities available at Horton, and have come for instruction in technique and to undertake researches into special problems related to malaria.

(C) Cooperation with Outside Bodies.

(1) London County Council.

(a) The London County Council have appointed a special whole-time medical officer (Dr. Hutton) to deal with the scientific aspects of general paralysis of the insane, particularly from the point of view of prophylaxis. This officer is in charge of the patients in the Malaria-Therapy Centre from whom the infective material is primarily derived.

(b) The London County Council has provided 6 rooms for the accommodation of the Ministry’s Malaria Unit at Horton. They also pay for the upkeep of these rooms, provide for the expenditure on electricity, water and rates, and supply the staff for keeping these rooms clean, etc.

(c) A few years ago the London County Council increased the number of special beds for malaria-therapy work up to 21 and have now almost finished a new extension by which this number will become 31. This increase will greatly facilitate the provision of infective material by the Ministry.

(d) The Malaria-Therapy Hospital financed by the London County Council is the primary source of all the infective material distributed by the Ministry. Without this help and collaboration it would not be possible to cope with the demands for such material. As noted above, the London County Council have gone to very considerable expense in expanding their accommodation for patients, and this means that suitable cases are almost always available as a source from which infective material can be obtained without undue delay.

(e) The policy of the London County Council is to collect all their G.P.I. cases at Horton Hospital, so a large number are under observation there. (During 1938, a total of 223 malaria transmissions were carried out at Horton.) With Dr. Hutton’s help a careful study can be made of large numbers of patients, variations in treatment tried out, and the after-results scientifically evaluated.

(2) The London School of Hygiene and Tropical Medicine.

(a) The school pays Leiut.-Colonel Sinton £150 per annum to act as adviser on malaria to the Ministry’s Malaria Laboratory at Horton.

(b) The London School also provides Col. Sinton, in his capacity as Manson Fellow, with an assistant who receives £3 per week. This assistant often helps in the routine work of the Malaria Laboratory. In addition it provides equipment needed in connection with Col. Sinton’s researches.

(c) Mr. Shute is given an honororium of £25 a year for demonstration and teaching work in connection with the malaria classes which visit Horton from the School, and also for the supply of teaching material.

(d) Dr. Nicol, Medical Superintendent of the Horton Hospital, receives an honorarium of £75 per annum from the School (of which one-third goes to the London County Council) for lecturing on malaria to students of the School both there and at Horton.

(3) The Royal Society of London.

This society pays the salary of Colonel Sinton (£600 per annum) to undertake research work. The fact that he has elected to carry out this work at Horton is fortunate from the point of view of the Ministry, as he is always available there to superintend and help the work at the Minstry’s Laboratory.

...

T.C., January, 1939.

 

Appendix I.

Details of the Distribution of Infective Material for the Practice of Malaria-Therapy during the Year `938.

(1) Type of Infective Material Used.

Number of cases infected by:-

Blood. Mosquitoes.

Benign tertian malaria. 338 263

Quartan malaria. 41 ---

Malignant tertian malaria. 7 20

Ovale malaria. 19 44

Total 405 327

Grand total 732.

(2) Diseases Treated.

Number of Cases.

General Paralysis of the Insane 678

Juvenile General Paralysis 4

Tabes 35

Optic Atrophy 5

Neuro-syphilis 5

Menigo-vascular syphilis 4

Mycosis fungoides 2

Disseminated Sclerosis 1

Arthritis 1

Total 735.

(3) Geographical Distribution of Infective Material.

London 142

Yorkshire 41

Essex 20

Isle of Wight 1

Devonshire 15

Durham 13

Cheshire 21

Lancashire 12

Kent 16

Wiltshire 1

Hampshire 23

Surrey 13

Horton 223

Warwickshire 33

Hertfordshire 9

Lincolnshire 3

Nottinghamshire 8

Leicestershire 9

Staffordshire 8

Gloucestershire 7

Cambridgeshire 1

Dorsetshire 2

Suffolk 6

Buckinghamshire 7

Derbyshire 4

Middlesex 3

Shropshire 6

Wiltshire 2

Oxfordshire 3

Northamptonshire 5

Sussex 12

Cornwall 4

Northumberland 4

Bedfordshire 3

Cumberland 3

Berkshire 1

Norfolk 2

WALES 16

SCOTLAND 23

IRELAND (Eire) 6

(Two lots of quartan blood were also sent to Roumania, and one of ovale to Germany).

(4) Institutions.

The number of hospitals in England and Wales which have been supplied frequently with infective material is about 280 at present.’]