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BACTERIA AND CHRONIC BRONCHITIS
734
affect children born afterwards; but, in experiments on the pregnant mouse, doses as low as 25r have produced 3 The a significant number of detectable deformities. Adrian Committee concluded that the effects of even the small amounts used in antenatal radiography were still sub judice.4 There is no certain proof that pregnancy will reduce the survival chances of a woman who has already been treated for cancer of the breast. Brown’s advice1 is that, if she was originally in stage 2, if the pregnancy is in its early months, and if she has small children who need her, she should have therapeutic abortion, especially if less than four or five years have elapsed since she was treated. If she was in stage 1, if she has no children, and if she wants a child, she should not be dissuaded. But there must always be some anxiety about the subsequent fate of the child. When first seen, 2% of patients with cancer of the breast are pregnant, and it is estimated that of 10,000 pregnant women 3 have this form of carcinoma. Brown is not prepared to say whether the woman whose cancer is discovered during pregnancy will be harmed by going to term. Undoubtedly the concentration of oestrogen increases with the progress of pregnancy until just before parturition, and this must be a factor in hormonedependent cases. But we cannot readily distinguish these, and the need for treatment is urgent. Again the chances of a woman bearing a baby after an operation like radical mastectomy are not good; and if radiotherapy is required it may (as already stated) prove dangerous for the foetus. The cases, therefore, in which pregnancy should be allowed to take its course when cancer is discovered seem to be restricted to those in which religious beliefs forbid termination and those in which the women desperately want a child. BACTERIA AND CHRONIC BRONCHITIS
THE sputum of patients with chronic bronchitis commonly contains Hamophilus infiuenzae 5; but in some instances the organism will not be detected unless a technique is used which excludes overgrowth by the pharyngeal bacteria contaminating the sputum. Another difficulty is that pathogens may be irregularly distributed in the sputum, and the time-honoured method of taking a single sample with a wire loop may fail to reveal them.s Error in the reverse sense can arise when pneumococci, H. influenzce, and other potential bronchial pathogens are present in the nasopharynx of people who have no bronchial infection. 78 Brumfitt et awl. investigated the bronchial flora by swabbing the bronchi directly, through a bronchoscope. Swabs taken from 42 patients with normal bronchi were sterile, whereas H. infiuenzae was isolated from 18 of the 19 patients with chronic bronchitis, even though some of these were in remission when the swabs were taken. Cultures were also made from sputum and throat swabs, and sputum examination was shown to be misleading owing to contamination by the potential pathogens of the 3. Russell, L. B. Proc. Soc. exp. Biol., N.Y. 1957, 95, 174. 4. Hazards to Man of Nuclear and Allied Reactions: A Second Report to the Medical Research Council. Cmnd. 1225. 1960. H.M. Stationery Office. 5. Mulder, J. Acta med. scand. 1938, 94, 98. 6. May, J. R. Lancet, 1952, ii, 1206. 7. Straker, E., Hill, A. B., Lovell, R. Rep. publ. Hlth med. Subj., Lond. 1939, no. 90. 8. Masters, P. L., Brumfitt, W., Mendez, R. L., Likar, M. Brit. med. J. 9.
1958, i, 1200. Brumfitt, W., Willoughby, ii, 1306.
M. L.
N., Bromley, L. L. Lancet, 1957,
pharynx. Laurenzi et al.10 have confirmed these findings, and have further studied the importance of oral and pharyngeal contamination of sputum. A relatively harmless organism, Chromobacterium prodigiosum, was introduced into the mouth or pharynx of 14 patients with purulent sputum. It had previously been claimed that pharyngeal contaminants could be removed by washing small pieces of purulent sputum in three changes of physiological saline6 11; but Laurenzi et al. found that no fewer than nine washings were required. Clearly, then, skill is needed in assessing the flora of the sputum, and special techniques must be used. 12 13 The significance of H. infiuenzae in chronic bronchitis-and more particularly in the acute exacerbations of chronic bronchitis-is still uncertain. Two-thirds of patients with the disease have, in their serum, high titres of antibody to H. infiuenzae; but acute episodes do not cause a further rise in titre. 14 Possibly, infection of the bronchi follows a failure in the antibacterial mechanisms which normally preserve sterility of the bronchopulmonary tree. For example, mucous-gland hyperplasia and excessive mucous production are always found in chronic bronchitis 15-17 and probably facilitate infection. Cigarette-smoking is known to play an important role,18 and has recently been shown greatly to increase the incidence of the disease in the elderly.19s There has been a good deal of debate as to whether chemotherapy should be given prophylactically or reserved for acute episodes. From his experience in general practice, Handheld-Jones 20 is strongly in favour of the latter course. He supplied patients with sputum containers and tetracycline tablets, and told them to collect sputum at the first signs of infection and then to start taking the antibiotic. When Escherichia coli, Proteus vulgaris, and Klebsiella aerogenes were isolated, these were sometimes resistant to tetracyclines and alternative treatment was necessary. Other reports 21-23 have suggested that Esch. coli may occasionally be important in chronic bronchitis, especially in patients receiving antibiotics. Gandevia and Cowling 24 provide further evidence of this: in a long-term study of 17 patients, they found that Esch. coli was the only likely pathogen in 3; they isolated the organism consistently from 2 others. They conclude that coliform organisms can occasionally infect the bronchial mucosa, although their presence in the sputum of chronic bronchitics may not always be significant. Examination of the sputum is important for diagnosing and treating all bacterial infections of the lower respiratory tract. But lessons learnt in the study of chronic bronchitis are equally relevant to other infections: only by the proper collection of specimens, the application of reliable laboratory techniques, and the cautious analysis of results, can wrong conclusions be avoided. Laurenzi, G. A., Potter, R. T., Kass, E. H. New Engl. J. Med. 1961, 265, 1273. 11. Mulder, J., Goslings, W. R. C., Van der Plas, M. C., Lopes Cardozo, P. Acta med. scand. 1952, 143, 32. 12. Allibone, E. C., Allison, P. R., Zimmermann, K. Brit. med. J. 1956, i, 1457. 13. May, J. R. Lancet, 1953, ii, 543. 14. Glynn, A. A. Brit. med. J. 1959, ii, 911. 15. Florey, H., Carleton, H. M., Wells, A. Q. Brit. J. exp. Path. 1932, 13, 269. 16. Reid, L. McA. Lancet, 1954, i, 275. 17. Glynn, A. A., Michaels, L. Thorax, 1960, 15, 142. 18. Oswald, N. C., Medvei, V. C. Lancet, 1955, ii, 843. 19. Fry, J. J. Coll. gen. Pract. 1962, 5, 54. 20. Handfield-Jones, R. P. C. ibid. 1962, 5, 43. 21. Brumfitt, W., Willoughby, M. L. N. Lancet, 1958, i, 132. 22. Aspin, J., Howells, C. H. L. ibid. 1960, ii, 872. 23. Leigh, R. E. D. ibid. p. 1087. 24. Gandevia, B., Cowling, D. C. Aust. Ann. Med. 1961, 10, 275. 10.
affect children born afterwards; but, in experiments on the pregnant mouse, doses as low as 25r have produced 3 The a significant number of detectable deformities. Adrian Committee concluded that the effects of even the small amounts used in antenatal radiography were still sub judice.4 There is no certain proof that pregnancy will reduce the survival chances of a woman who has already been treated for cancer of the breast. Brown’s advice1 is that, if she was originally in stage 2, if the pregnancy is in its early months, and if she has small children who need her, she should have therapeutic abortion, especially if less than four or five years have elapsed since she was treated. If she was in stage 1, if she has no children, and if she wants a child, she should not be dissuaded. But there must always be some anxiety about the subsequent fate of the child. When first seen, 2% of patients with cancer of the breast are pregnant, and it is estimated that of 10,000 pregnant women 3 have this form of carcinoma. Brown is not prepared to say whether the woman whose cancer is discovered during pregnancy will be harmed by going to term. Undoubtedly the concentration of oestrogen increases with the progress of pregnancy until just before parturition, and this must be a factor in hormonedependent cases. But we cannot readily distinguish these, and the need for treatment is urgent. Again the chances of a woman bearing a baby after an operation like radical mastectomy are not good; and if radiotherapy is required it may (as already stated) prove dangerous for the foetus. The cases, therefore, in which pregnancy should be allowed to take its course when cancer is discovered seem to be restricted to those in which religious beliefs forbid termination and those in which the women desperately want a child. BACTERIA AND CHRONIC BRONCHITIS
THE sputum of patients with chronic bronchitis commonly contains Hamophilus infiuenzae 5; but in some instances the organism will not be detected unless a technique is used which excludes overgrowth by the pharyngeal bacteria contaminating the sputum. Another difficulty is that pathogens may be irregularly distributed in the sputum, and the time-honoured method of taking a single sample with a wire loop may fail to reveal them.s Error in the reverse sense can arise when pneumococci, H. influenzce, and other potential bronchial pathogens are present in the nasopharynx of people who have no bronchial infection. 78 Brumfitt et awl. investigated the bronchial flora by swabbing the bronchi directly, through a bronchoscope. Swabs taken from 42 patients with normal bronchi were sterile, whereas H. infiuenzae was isolated from 18 of the 19 patients with chronic bronchitis, even though some of these were in remission when the swabs were taken. Cultures were also made from sputum and throat swabs, and sputum examination was shown to be misleading owing to contamination by the potential pathogens of the 3. Russell, L. B. Proc. Soc. exp. Biol., N.Y. 1957, 95, 174. 4. Hazards to Man of Nuclear and Allied Reactions: A Second Report to the Medical Research Council. Cmnd. 1225. 1960. H.M. Stationery Office. 5. Mulder, J. Acta med. scand. 1938, 94, 98. 6. May, J. R. Lancet, 1952, ii, 1206. 7. Straker, E., Hill, A. B., Lovell, R. Rep. publ. Hlth med. Subj., Lond. 1939, no. 90. 8. Masters, P. L., Brumfitt, W., Mendez, R. L., Likar, M. Brit. med. J. 9.
1958, i, 1200. Brumfitt, W., Willoughby, ii, 1306.
M. L.
N., Bromley, L. L. Lancet, 1957,
pharynx. Laurenzi et al.10 have confirmed these findings, and have further studied the importance of oral and pharyngeal contamination of sputum. A relatively harmless organism, Chromobacterium prodigiosum, was introduced into the mouth or pharynx of 14 patients with purulent sputum. It had previously been claimed that pharyngeal contaminants could be removed by washing small pieces of purulent sputum in three changes of physiological saline6 11; but Laurenzi et al. found that no fewer than nine washings were required. Clearly, then, skill is needed in assessing the flora of the sputum, and special techniques must be used. 12 13 The significance of H. infiuenzae in chronic bronchitis-and more particularly in the acute exacerbations of chronic bronchitis-is still uncertain. Two-thirds of patients with the disease have, in their serum, high titres of antibody to H. infiuenzae; but acute episodes do not cause a further rise in titre. 14 Possibly, infection of the bronchi follows a failure in the antibacterial mechanisms which normally preserve sterility of the bronchopulmonary tree. For example, mucous-gland hyperplasia and excessive mucous production are always found in chronic bronchitis 15-17 and probably facilitate infection. Cigarette-smoking is known to play an important role,18 and has recently been shown greatly to increase the incidence of the disease in the elderly.19s There has been a good deal of debate as to whether chemotherapy should be given prophylactically or reserved for acute episodes. From his experience in general practice, Handheld-Jones 20 is strongly in favour of the latter course. He supplied patients with sputum containers and tetracycline tablets, and told them to collect sputum at the first signs of infection and then to start taking the antibiotic. When Escherichia coli, Proteus vulgaris, and Klebsiella aerogenes were isolated, these were sometimes resistant to tetracyclines and alternative treatment was necessary. Other reports 21-23 have suggested that Esch. coli may occasionally be important in chronic bronchitis, especially in patients receiving antibiotics. Gandevia and Cowling 24 provide further evidence of this: in a long-term study of 17 patients, they found that Esch. coli was the only likely pathogen in 3; they isolated the organism consistently from 2 others. They conclude that coliform organisms can occasionally infect the bronchial mucosa, although their presence in the sputum of chronic bronchitics may not always be significant. Examination of the sputum is important for diagnosing and treating all bacterial infections of the lower respiratory tract. But lessons learnt in the study of chronic bronchitis are equally relevant to other infections: only by the proper collection of specimens, the application of reliable laboratory techniques, and the cautious analysis of results, can wrong conclusions be avoided. Laurenzi, G. A., Potter, R. T., Kass, E. H. New Engl. J. Med. 1961, 265, 1273. 11. Mulder, J., Goslings, W. R. C., Van der Plas, M. C., Lopes Cardozo, P. Acta med. scand. 1952, 143, 32. 12. Allibone, E. C., Allison, P. R., Zimmermann, K. Brit. med. J. 1956, i, 1457. 13. May, J. R. Lancet, 1953, ii, 543. 14. Glynn, A. A. Brit. med. J. 1959, ii, 911. 15. Florey, H., Carleton, H. M., Wells, A. Q. Brit. J. exp. Path. 1932, 13, 269. 16. Reid, L. McA. Lancet, 1954, i, 275. 17. Glynn, A. A., Michaels, L. Thorax, 1960, 15, 142. 18. Oswald, N. C., Medvei, V. C. Lancet, 1955, ii, 843. 19. Fry, J. J. Coll. gen. Pract. 1962, 5, 54. 20. Handfield-Jones, R. P. C. ibid. 1962, 5, 43. 21. Brumfitt, W., Willoughby, M. L. N. Lancet, 1958, i, 132. 22. Aspin, J., Howells, C. H. L. ibid. 1960, ii, 872. 23. Leigh, R. E. D. ibid. p. 1087. 24. Gandevia, B., Cowling, D. C. Aust. Ann. Med. 1961, 10, 275. 10.