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HEPATITIS AND THE ARTIFICIAL KIDNEY
1000
passive immunisation with adsorbed toxoid. In patients physician and a staff nurse who had been in contact with already partially immunised, the active element elicits a these patients also fell ill with hepatitis, and they rapid antigenic response, while in those not previously recovered. About the same time publicity was given to immunised it initiates lasting protection. Simultane- the case of a hospital porter employed at the Manchester Royal Infirmary who died from hepatitis while on his ously the passive element confers immediate protection. honeymoon; but this porter had not been in contact with It is thus reassuring to see that the traditional disthe dialysis unit. In addition a patient with chronic renal advantages associated with the combined immunisation failure who was having repeated haemodialysis showed (the possible weakening of antigenic stimulus in the signs of infectious hepatitis; a doctor who had been attendpresence of the passive agent) are being discounted. ing this patient later contracted the disease, but in a Universal routine immunisation in childhood would demand only a booster dose of toxoid for the injureda completely safe procedure. But this ideal is unlikely to be attained, and the problem of adequate yet safe protection for those with doubtful immunity remains. If Cox’s conclusions are accepted, emergency passive immunisation with antisera from any source may be discontinued. If, however, a more cautious view is taken (which is likely) prophylaxis is best obtained with human A.T.G. and adsorbed toxoid given simultaneously and supplemented by further toxoid in the hitherto unprotected. Until supplies of A.T.G. are adequate, or until the efficacyof Cox’s method is established beyond doubt, we shall have to depend largely on equine or bovine antisera.
Annotations HEPATITIS AND THE ARTIFICIAL KIDNEY
AN investigation into possible causes of the infectious hepatitis that has affected members of the staff of the Manchester Royal Infirmary has brought to light a connection between this infection and the procedures involved in artificial dialysis for the treatment of acute and chronic renal failure. Manchester Royal Infirmary, like other general hospitals, regularly admits patients who have infectious hepatitis; other patients are diagnosed as acute or subacute yellow atrophy of the liver " and some among them are likely to have infectious hepatitis;
form, since he had previously received prophylactic a-globulin. Hepatitis is known to be spread by blood or blood fractions and by faecal contamination. Those who attend patients undergoing dialysis for the treatment of renal disease may be repeatedly exposed to contamination from modified
both these sources. Once the connection between the hepatitis and the dialysis unit was realised, preventive All the technical promeasures were put into force. cedures were studied afresh so that exposure to possible contamination could be eliminated as far as possible, and a senior technician was appointed to help the hospital’s control-of-infection officer in this work. We lately discussedthe place of a-globulin in the prophylaxis of hepatitis, and a-globulin was in fact given to all staff who had been in contact with these hepatitis patients and with the affected members of the staff. A special study of this unsuspected complication of dialysis has been undertaken, and local authorities have been asked whether infectious hepatitis could be made notifiable, so that possible risks could be assessed in advance. Meanwhile, the use of the artificial kidney for the treatment of renal failure, especially for acute renal failure, is being continued at the Manchester Royal Infirmary, since it has achieved a revolution in the rate of recovery in these patients. In due course we can expect a full account of this complication and the measures taken to deal with it.
"
the distinction is difficult since we can neither detect the virus nor measure cifculating neutralising antibodies. In 1964, 26 patients with these conditions were admitted to the Manchester Royal Infirmary and 7 died, all in the yellow-atrophy group; in 1965 so far some 30 cases have been admitted with 8 deaths, 2 of which were among the infectious-hepatitis group; these figures do not include the staff cases. The figures for 1964 and 1965 were somewhat higher than for the previous two years, but they were not really exceptional. The Manchester Royal Infirmary employs over 1000 persons, so it is not surprising that occasionally a member of the medical, nursing, or lay staff is affected by infectious hepatitis. But in the spring of this year three members of the staff, a surgical registrar, a male nurse, and a female staff nurse had severe infectious hepatitis, and the staff nurse died. Investigation showed that the only connecting link between the three was a patient with acute renal failure admitted for hsemodialysis, the surgeon had attended to the patient’s pericardial effusion. This patient did develop jaundice, and later two technicians engaged in handling material from the patient in the laboratory also became affected, but recovered. In the meantime two other patients admitted from other hospitals for dialysis treatment were found to have infectious hepatitis, and one of them died. Later a house-
TOO LITTLE CHANGE
IN the 19th century the sale of alleged abortifacients widespread and their cost exorbitant.2 A survey made by the Birmingham group of the Abortion Law Reform Association 3 suggests that in the 20th century the position is little changed. Two women and one man, as investigators for the group, visited 40 shops, mostly in London and Birmingham. The women began by asking for something to was
bring on a delayed period, becoming more explicit during the conversation. The man said that his girl friend’s period was late. Much the same line was taken by the vendor whether the purchaser was male or female. Of 20 chemists’ shops 3 had nothing to offer; of 17 rubbergoods shops 5 had nothing; and of 3 herbalists 1 had nothing. Chemists offered a greater variety of preparations-e.g., ’Ergo-Apiol ’ and ’Apioline ’-while rubbergoods shops dealt mainly with pills such as ’Menoroids ’. The request for a remedy,of this kind caused no surprise, and the impression gained was that it was commonplace. A further question of "Will they work and stop a pregnancy ? elicited such replies as They work in 80% of cases," or They should do, we sell a "
"
"
1. Lancet, Oct. 2, 1965, ii, 674. 2. More Secret Remedies; chapter 13. London, 1912. 3. Survey of Abortifacient Drugs. Obtainable from Mrs. D. E. Cossey, 19, Kenneth Court, 173, Kennington Road, London, S.E.11.
passive immunisation with adsorbed toxoid. In patients physician and a staff nurse who had been in contact with already partially immunised, the active element elicits a these patients also fell ill with hepatitis, and they rapid antigenic response, while in those not previously recovered. About the same time publicity was given to immunised it initiates lasting protection. Simultane- the case of a hospital porter employed at the Manchester Royal Infirmary who died from hepatitis while on his ously the passive element confers immediate protection. honeymoon; but this porter had not been in contact with It is thus reassuring to see that the traditional disthe dialysis unit. In addition a patient with chronic renal advantages associated with the combined immunisation failure who was having repeated haemodialysis showed (the possible weakening of antigenic stimulus in the signs of infectious hepatitis; a doctor who had been attendpresence of the passive agent) are being discounted. ing this patient later contracted the disease, but in a Universal routine immunisation in childhood would demand only a booster dose of toxoid for the injureda completely safe procedure. But this ideal is unlikely to be attained, and the problem of adequate yet safe protection for those with doubtful immunity remains. If Cox’s conclusions are accepted, emergency passive immunisation with antisera from any source may be discontinued. If, however, a more cautious view is taken (which is likely) prophylaxis is best obtained with human A.T.G. and adsorbed toxoid given simultaneously and supplemented by further toxoid in the hitherto unprotected. Until supplies of A.T.G. are adequate, or until the efficacyof Cox’s method is established beyond doubt, we shall have to depend largely on equine or bovine antisera.
Annotations HEPATITIS AND THE ARTIFICIAL KIDNEY
AN investigation into possible causes of the infectious hepatitis that has affected members of the staff of the Manchester Royal Infirmary has brought to light a connection between this infection and the procedures involved in artificial dialysis for the treatment of acute and chronic renal failure. Manchester Royal Infirmary, like other general hospitals, regularly admits patients who have infectious hepatitis; other patients are diagnosed as acute or subacute yellow atrophy of the liver " and some among them are likely to have infectious hepatitis;
form, since he had previously received prophylactic a-globulin. Hepatitis is known to be spread by blood or blood fractions and by faecal contamination. Those who attend patients undergoing dialysis for the treatment of renal disease may be repeatedly exposed to contamination from modified
both these sources. Once the connection between the hepatitis and the dialysis unit was realised, preventive All the technical promeasures were put into force. cedures were studied afresh so that exposure to possible contamination could be eliminated as far as possible, and a senior technician was appointed to help the hospital’s control-of-infection officer in this work. We lately discussedthe place of a-globulin in the prophylaxis of hepatitis, and a-globulin was in fact given to all staff who had been in contact with these hepatitis patients and with the affected members of the staff. A special study of this unsuspected complication of dialysis has been undertaken, and local authorities have been asked whether infectious hepatitis could be made notifiable, so that possible risks could be assessed in advance. Meanwhile, the use of the artificial kidney for the treatment of renal failure, especially for acute renal failure, is being continued at the Manchester Royal Infirmary, since it has achieved a revolution in the rate of recovery in these patients. In due course we can expect a full account of this complication and the measures taken to deal with it.
"
the distinction is difficult since we can neither detect the virus nor measure cifculating neutralising antibodies. In 1964, 26 patients with these conditions were admitted to the Manchester Royal Infirmary and 7 died, all in the yellow-atrophy group; in 1965 so far some 30 cases have been admitted with 8 deaths, 2 of which were among the infectious-hepatitis group; these figures do not include the staff cases. The figures for 1964 and 1965 were somewhat higher than for the previous two years, but they were not really exceptional. The Manchester Royal Infirmary employs over 1000 persons, so it is not surprising that occasionally a member of the medical, nursing, or lay staff is affected by infectious hepatitis. But in the spring of this year three members of the staff, a surgical registrar, a male nurse, and a female staff nurse had severe infectious hepatitis, and the staff nurse died. Investigation showed that the only connecting link between the three was a patient with acute renal failure admitted for hsemodialysis, the surgeon had attended to the patient’s pericardial effusion. This patient did develop jaundice, and later two technicians engaged in handling material from the patient in the laboratory also became affected, but recovered. In the meantime two other patients admitted from other hospitals for dialysis treatment were found to have infectious hepatitis, and one of them died. Later a house-
TOO LITTLE CHANGE
IN the 19th century the sale of alleged abortifacients widespread and their cost exorbitant.2 A survey made by the Birmingham group of the Abortion Law Reform Association 3 suggests that in the 20th century the position is little changed. Two women and one man, as investigators for the group, visited 40 shops, mostly in London and Birmingham. The women began by asking for something to was
bring on a delayed period, becoming more explicit during the conversation. The man said that his girl friend’s period was late. Much the same line was taken by the vendor whether the purchaser was male or female. Of 20 chemists’ shops 3 had nothing to offer; of 17 rubbergoods shops 5 had nothing; and of 3 herbalists 1 had nothing. Chemists offered a greater variety of preparations-e.g., ’Ergo-Apiol ’ and ’Apioline ’-while rubbergoods shops dealt mainly with pills such as ’Menoroids ’. The request for a remedy,of this kind caused no surprise, and the impression gained was that it was commonplace. A further question of "Will they work and stop a pregnancy ? elicited such replies as They work in 80% of cases," or They should do, we sell a "
"
"
1. Lancet, Oct. 2, 1965, ii, 674. 2. More Secret Remedies; chapter 13. London, 1912. 3. Survey of Abortifacient Drugs. Obtainable from Mrs. D. E. Cossey, 19, Kenneth Court, 173, Kennington Road, London, S.E.11.