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CARRIERS OF ENTERIC
535
CARRIERS OF ENTERIC IN Great Britain the abolition, with
rare
exceptions, of gross contamination of watersupplies has reduced morbidity and mortality from enteric fever to small proportions. But this fall in incidence has, if possible, enhanced the importance of chronic carriers who are now the chief causes of epidemic outbreaks both in the community at large and in institutions. Prof. C. H. BROWNING and his associates in Glasgow have therefore rendered a valuable service in undertaking to reportupon this problem in the light of their own researches and those of others. Enteric carriers may be classified according to the duration of the carrier state, and also according to the route of excretion of the specific organisms. It has been shown that, in paratyphoid B infections especially, the incidence of temporary carriers in convalescence is high, and the report therefore lays stress on precautions against the spread of infection during the convalescent period. In some cases the carrier state may set in several months after convalescence, and its occasional intermittency is also a factor which adds to the difficulties of control ; intervals of infectivity " may be separated by non-infective periods of years." Most of those who continue to excrete bacilli for six months after the acute attack will continue to do so. Those who still excrete after a year, fortunately a small proportion only, will not clear spontaneously ; the carrier state becomes chronic or permanent. The chronic carrier after a known attack of enteric fever is sufficiently dangerous, but in the investigation of an outbreak the history of the illness at least provides a clue to a possible source of infection. More dangerous, because more elusive, is the chronic carrier who has had no known attack or whose carrier state is intermittent. The two main routes of excretion are fsecal and urinary; it is also well recognised that bone sinuses, or subcutaneous abscesses, may continue to yield pure cultures for long periods. The chronic faecal carrier or excreter is " usually a married woman of 30 years of age or upward." Female chronic carriers exceed male carriers in the proportion of four or five to one. Children rarely become chronic carriers, but are important agents in dissemination because the attack is so often mild and atypical. Faecal " " carriers, who are occasionally mixed carriers of B. typhosus and paratyphosus, are far the most numerous class and may be further subdivided into the biliary carrier (gall-bladder or liver and bile-ducts, or both) and the rare true intestinal carrier. Although chronic cholecystitis, usually but not always associated with gall-stones, has been found in a large proportion of faecal carriers, cases have occurred in which the biliary system could be held blameless, the focus being strictly 1 Chronic Enteric Carriers and their Treatment. By C. H. Browning, with H. L. Coulthard, R. Cruickshank, K. J. Guthrie, and R. P. Smith: Medical Research Council, Spec. Report Series No. 179. London: H.M. Stationery Office. 1933. Pp. 80. 1s. 6d.
intestinal. Not only may gall-stones be absent but the gall-bladder may show comparatively slight naked-eye changes such as thickening of the mucosa. Histologically, the most marked change observed by the authors of the report consisted in "localised and diffuse collections of cells in the mucosa, which are mainly plasma cells and lymphocytes with scanty eosinophiles." They think there is considerable support for GARBAT’s view that the gall-bladder in these "a test-tube containing the bile carriers acts< as medium in which the typhoid bacteria propagate without affecting the gall-bladder itself-." Urinary carriers, although less numerous, are clearly more dangerous than faecal carriers. Not only are the opportunities for spreading infection greater, but the organisms occur in large numbers in the urine and not uncommonly in pure culture. The nidus of infection appears to be " most commonly situated in the kidney or kidney pelvis." That one kidney only may be infected has been shown by means of ureteral catheterisation and the clearance of the carrier state after the removal of the unilateral lesion. Apart from careful treatment and nursing and the provision of a high calorie diet during the acute and convalescent stages, is it possible to prevent or lessen the possibility of the patient becoming a carrier ? Prophylactic inoculation diminishes the incidence of clinical attacks. When attacks do occur in the inoculated they tend to be slight, and it has been held by some that carriers after such modified attacks are less numerous. Others, however, have not been able to confirm this. General anti-enteric inoculation of any population liable to exposure is not practicable in peacetime. But the same measure applied to closed communities such as the staff and inmates of mental hospitals is not only practicable but highly desirable. Prof. BROWNING and his colleagues point out that although this measure be adopted the carrier must still be searched for and treated, since amongst the recently vaccinated massive infection may yet result in an epidemic. It is well known also that the protection afforded by inoculation with T.A.B. tends to wane after a year, and to secure full protection thereafter the process must be repeated. It is advised that in addition to bacteriological evidence of freedom from infection before discharge of a case from hospital, examinations should again be made six to twelve months later, compulsory powers being exercised by all authorities in order to obtain the necessary specimens from convalescents and suspects. In Scotland, under Article 13 of the Public Health (Infectious Diseases) Regulations, 1932, it is possible to notify and to remove compulsorily a carrier, subject to the certificate being renewed every three months. In England powers exist merely to prevent enteric carriers from being concerned in the preparation or handling of food or drink for human consumption. In America regulations for the control of carriers are much more comprehensive and drastic. The authors of the report consider that the existing accommodation, usually an isolation hospital, for the investigation and
536 treatment
of carriers
involving bacteriological, cholecystectomy has been successful in terminating radiological, urological, and operative procedures the carrier state in 75 per cent. of cases. Failures is not adequate. This is certainly true of many may have been due to the fact that the patients small fever hospitals, but several of the large were purely intestinal carriers who cannot be institutions already possess, or can readily provide, detected with certainty before operation. It the necessary facilities. seems clear that just as the chronic carrier state In the treatment of the chronic faecal carrier in diphtheria is most certainly terminated by the chemotherapy, physiotherapy, and the administra- removal of infected tonsils and adenoids, so tion of B. acidophilu8, with a view to changing the surgical measures offer by far the best chance of reaction of the intestinal flora, alike proved success for the cure of the chronic enteric carrier. ineffective. Vaccine therapy, including Besredka’s In both conditions much expenditure of time and oral bile-vaccines, produced no better results. money will be saved when this fact is generally Where the gall-bladder is the site of infection recognised.
ANNOTATIONS THE HUME LECTURES IN opening the review, of which we publish the conclusion this week, Mr. H. Morriston Davies said it seemed to him a fitting tribute. to the memory of George Haliburton Hume that the subject matter selected for the first lecture on surgery under his name should be thoracic surgery. A contemporary of Lauder Brunton and a pupil of Syme, Hume witnessed the complete development of Listerian methods ; to his knowledge obtained in this country, he added that acquired by prolonged visits abroad, notably in Berlin and Vienna. Hume was on the active staff of the Royal Infirmary, Newcastle-uponTyne, for 34 years, and as chairman of the staff took a prominent part in the building of the new Infirmary, being instrumental in obtaining a gift of jE 100,000 from Mr. John Hall and many other - contributions. He was three times president of the Northern Counties Medical Society, and the -esteem in which he was held was manifested by the society commemorating his name by endowing the George Haliburton Hume lectures. The interest taken by Hume in surgery and in its progress made it right, said Mr. Morriston Davies, to pause a moment to consider why the advance of chest surgery lagged so far behind the surgery of other parts ,of the body. The first real advance in surgical treatment was made possible by the discoveries of Lister ; the terrors were in great part allayed by the introduction of antiseptics and of narcotics. Operative treatment became a practical science and advanced with rapidly increasing strides. Operations ,on the abdomen, on the limbs, and on the head and neck, ceased to be those only of urgent necessity. The brain alone, other than the thorax, resisted for a time an increasingly successful response to surgical skill. Soon however the mechanical conditions of the skull and brain became understood while the thorax remained not Victorian but preVictorian in its imperviousness to modern methods ;
unresponsive
to
surgical skill, repaying usually by
the death of the patient any efforts more heroic than those of previous decades-one might almost say centuries. The last 15 to 20 years had, however, The .seen a change almost incredible in its rapidity. surgery of the chest had suddenly ceased to be a dark reproach on this science ; it had become instead ,an illuminating example of what could be accomplished once the fundamental principles of anatomy, of physiology, and of the mechanical peculiarities .of the region, in addition to the pathology of the disease, were understood. In pulmonary tuberculosis the value of surgical treatment has long passed the experimental stage.
Collapse therapy,
as
Mr. Morriston Davies remarks
in his
summing up, will save life, in many cases restoring the individual to working capacity. For many it will enable healing to take place and will shorten the period of treatment. The more drastic forms of this therapy may give individuals life and unobtainable, but in the matter of thoracic surgery, he adds, this country is still sadly behind America, Scandinavia, and other continental countries. Only Wales and a few counties, it seems, give their tuberculous patients every modern aid in treatment, but there are indications of a rapid change. A recent meeting of the West London Medicohealth otherwise
Chirurgical Society was given up entirely to discussing artificial pneumothorax and Dr. F. E. Saxby Willis laid down clearly the indications for its employment. The director of the Michigan State sanatorium for tuberculosis has recently given his conclusionthat the majority, not the minority, of cases of active pulmonary tuberculosis are suitable for collapse therapy in some form ; and very striking is the allocation of two whole numbers2 of an important French journal to the surgical treatment of pulmonary tuberculosis, one of these numbers containing an admirable summary of the work of Prof. J. Sebrechts at the Hopital St.Jean at Bruges. The editorial committee of the journal points out that the experience of the last few years is pointing in rather a new direction. The surgeon, instead of embarking at once on a total thoracoplasty, is attempting to achieve various forms of partial collapse more strictly adapted to the particular lesion before him. At Bruges in particular Sebrechts has concentrated on the obliteration of apical cavities by apicolysis ; in Davos where the technique of collapse has been brought to a high degree of efficiency by intrathoracic division of adhesions, Dr. G. Maurer never omits to emphasise the fact that every method must be considered in every case. It is no longer a question of the routine application of the method of Forlanini or the method of Sauerbruch. The Hume lecturer has given a lead in the application of means to ends in the practice of thoracic surgery. THE SMALL-POX
PROBLEM IN SWEDEN DURING the last few years the problems of small-pox and vaccination have been considered in Sweden in view of the occurrence there of cases of small-pox and the doubts raised by certain untoward incidents associated with vaccination both at home and abroad. These events were the subject of comment in the Swedish Riksdag as well as in the press, and in 1930 1 Jour. Amer. Med. Assoc., Feb. 4th, p. 315. 2 Arch. Méd.-Chir. de l’Appareil Respiratoire, 1932, Nos. 5 and 6.
CARRIERS OF ENTERIC IN Great Britain the abolition, with
rare
exceptions, of gross contamination of watersupplies has reduced morbidity and mortality from enteric fever to small proportions. But this fall in incidence has, if possible, enhanced the importance of chronic carriers who are now the chief causes of epidemic outbreaks both in the community at large and in institutions. Prof. C. H. BROWNING and his associates in Glasgow have therefore rendered a valuable service in undertaking to reportupon this problem in the light of their own researches and those of others. Enteric carriers may be classified according to the duration of the carrier state, and also according to the route of excretion of the specific organisms. It has been shown that, in paratyphoid B infections especially, the incidence of temporary carriers in convalescence is high, and the report therefore lays stress on precautions against the spread of infection during the convalescent period. In some cases the carrier state may set in several months after convalescence, and its occasional intermittency is also a factor which adds to the difficulties of control ; intervals of infectivity " may be separated by non-infective periods of years." Most of those who continue to excrete bacilli for six months after the acute attack will continue to do so. Those who still excrete after a year, fortunately a small proportion only, will not clear spontaneously ; the carrier state becomes chronic or permanent. The chronic carrier after a known attack of enteric fever is sufficiently dangerous, but in the investigation of an outbreak the history of the illness at least provides a clue to a possible source of infection. More dangerous, because more elusive, is the chronic carrier who has had no known attack or whose carrier state is intermittent. The two main routes of excretion are fsecal and urinary; it is also well recognised that bone sinuses, or subcutaneous abscesses, may continue to yield pure cultures for long periods. The chronic faecal carrier or excreter is " usually a married woman of 30 years of age or upward." Female chronic carriers exceed male carriers in the proportion of four or five to one. Children rarely become chronic carriers, but are important agents in dissemination because the attack is so often mild and atypical. Faecal " " carriers, who are occasionally mixed carriers of B. typhosus and paratyphosus, are far the most numerous class and may be further subdivided into the biliary carrier (gall-bladder or liver and bile-ducts, or both) and the rare true intestinal carrier. Although chronic cholecystitis, usually but not always associated with gall-stones, has been found in a large proportion of faecal carriers, cases have occurred in which the biliary system could be held blameless, the focus being strictly 1 Chronic Enteric Carriers and their Treatment. By C. H. Browning, with H. L. Coulthard, R. Cruickshank, K. J. Guthrie, and R. P. Smith: Medical Research Council, Spec. Report Series No. 179. London: H.M. Stationery Office. 1933. Pp. 80. 1s. 6d.
intestinal. Not only may gall-stones be absent but the gall-bladder may show comparatively slight naked-eye changes such as thickening of the mucosa. Histologically, the most marked change observed by the authors of the report consisted in "localised and diffuse collections of cells in the mucosa, which are mainly plasma cells and lymphocytes with scanty eosinophiles." They think there is considerable support for GARBAT’s view that the gall-bladder in these "a test-tube containing the bile carriers acts< as medium in which the typhoid bacteria propagate without affecting the gall-bladder itself-." Urinary carriers, although less numerous, are clearly more dangerous than faecal carriers. Not only are the opportunities for spreading infection greater, but the organisms occur in large numbers in the urine and not uncommonly in pure culture. The nidus of infection appears to be " most commonly situated in the kidney or kidney pelvis." That one kidney only may be infected has been shown by means of ureteral catheterisation and the clearance of the carrier state after the removal of the unilateral lesion. Apart from careful treatment and nursing and the provision of a high calorie diet during the acute and convalescent stages, is it possible to prevent or lessen the possibility of the patient becoming a carrier ? Prophylactic inoculation diminishes the incidence of clinical attacks. When attacks do occur in the inoculated they tend to be slight, and it has been held by some that carriers after such modified attacks are less numerous. Others, however, have not been able to confirm this. General anti-enteric inoculation of any population liable to exposure is not practicable in peacetime. But the same measure applied to closed communities such as the staff and inmates of mental hospitals is not only practicable but highly desirable. Prof. BROWNING and his colleagues point out that although this measure be adopted the carrier must still be searched for and treated, since amongst the recently vaccinated massive infection may yet result in an epidemic. It is well known also that the protection afforded by inoculation with T.A.B. tends to wane after a year, and to secure full protection thereafter the process must be repeated. It is advised that in addition to bacteriological evidence of freedom from infection before discharge of a case from hospital, examinations should again be made six to twelve months later, compulsory powers being exercised by all authorities in order to obtain the necessary specimens from convalescents and suspects. In Scotland, under Article 13 of the Public Health (Infectious Diseases) Regulations, 1932, it is possible to notify and to remove compulsorily a carrier, subject to the certificate being renewed every three months. In England powers exist merely to prevent enteric carriers from being concerned in the preparation or handling of food or drink for human consumption. In America regulations for the control of carriers are much more comprehensive and drastic. The authors of the report consider that the existing accommodation, usually an isolation hospital, for the investigation and
536 treatment
of carriers
involving bacteriological, cholecystectomy has been successful in terminating radiological, urological, and operative procedures the carrier state in 75 per cent. of cases. Failures is not adequate. This is certainly true of many may have been due to the fact that the patients small fever hospitals, but several of the large were purely intestinal carriers who cannot be institutions already possess, or can readily provide, detected with certainty before operation. It the necessary facilities. seems clear that just as the chronic carrier state In the treatment of the chronic faecal carrier in diphtheria is most certainly terminated by the chemotherapy, physiotherapy, and the administra- removal of infected tonsils and adenoids, so tion of B. acidophilu8, with a view to changing the surgical measures offer by far the best chance of reaction of the intestinal flora, alike proved success for the cure of the chronic enteric carrier. ineffective. Vaccine therapy, including Besredka’s In both conditions much expenditure of time and oral bile-vaccines, produced no better results. money will be saved when this fact is generally Where the gall-bladder is the site of infection recognised.
ANNOTATIONS THE HUME LECTURES IN opening the review, of which we publish the conclusion this week, Mr. H. Morriston Davies said it seemed to him a fitting tribute. to the memory of George Haliburton Hume that the subject matter selected for the first lecture on surgery under his name should be thoracic surgery. A contemporary of Lauder Brunton and a pupil of Syme, Hume witnessed the complete development of Listerian methods ; to his knowledge obtained in this country, he added that acquired by prolonged visits abroad, notably in Berlin and Vienna. Hume was on the active staff of the Royal Infirmary, Newcastle-uponTyne, for 34 years, and as chairman of the staff took a prominent part in the building of the new Infirmary, being instrumental in obtaining a gift of jE 100,000 from Mr. John Hall and many other - contributions. He was three times president of the Northern Counties Medical Society, and the -esteem in which he was held was manifested by the society commemorating his name by endowing the George Haliburton Hume lectures. The interest taken by Hume in surgery and in its progress made it right, said Mr. Morriston Davies, to pause a moment to consider why the advance of chest surgery lagged so far behind the surgery of other parts ,of the body. The first real advance in surgical treatment was made possible by the discoveries of Lister ; the terrors were in great part allayed by the introduction of antiseptics and of narcotics. Operative treatment became a practical science and advanced with rapidly increasing strides. Operations ,on the abdomen, on the limbs, and on the head and neck, ceased to be those only of urgent necessity. The brain alone, other than the thorax, resisted for a time an increasingly successful response to surgical skill. Soon however the mechanical conditions of the skull and brain became understood while the thorax remained not Victorian but preVictorian in its imperviousness to modern methods ;
unresponsive
to
surgical skill, repaying usually by
the death of the patient any efforts more heroic than those of previous decades-one might almost say centuries. The last 15 to 20 years had, however, The .seen a change almost incredible in its rapidity. surgery of the chest had suddenly ceased to be a dark reproach on this science ; it had become instead ,an illuminating example of what could be accomplished once the fundamental principles of anatomy, of physiology, and of the mechanical peculiarities .of the region, in addition to the pathology of the disease, were understood. In pulmonary tuberculosis the value of surgical treatment has long passed the experimental stage.
Collapse therapy,
as
Mr. Morriston Davies remarks
in his
summing up, will save life, in many cases restoring the individual to working capacity. For many it will enable healing to take place and will shorten the period of treatment. The more drastic forms of this therapy may give individuals life and unobtainable, but in the matter of thoracic surgery, he adds, this country is still sadly behind America, Scandinavia, and other continental countries. Only Wales and a few counties, it seems, give their tuberculous patients every modern aid in treatment, but there are indications of a rapid change. A recent meeting of the West London Medicohealth otherwise
Chirurgical Society was given up entirely to discussing artificial pneumothorax and Dr. F. E. Saxby Willis laid down clearly the indications for its employment. The director of the Michigan State sanatorium for tuberculosis has recently given his conclusionthat the majority, not the minority, of cases of active pulmonary tuberculosis are suitable for collapse therapy in some form ; and very striking is the allocation of two whole numbers2 of an important French journal to the surgical treatment of pulmonary tuberculosis, one of these numbers containing an admirable summary of the work of Prof. J. Sebrechts at the Hopital St.Jean at Bruges. The editorial committee of the journal points out that the experience of the last few years is pointing in rather a new direction. The surgeon, instead of embarking at once on a total thoracoplasty, is attempting to achieve various forms of partial collapse more strictly adapted to the particular lesion before him. At Bruges in particular Sebrechts has concentrated on the obliteration of apical cavities by apicolysis ; in Davos where the technique of collapse has been brought to a high degree of efficiency by intrathoracic division of adhesions, Dr. G. Maurer never omits to emphasise the fact that every method must be considered in every case. It is no longer a question of the routine application of the method of Forlanini or the method of Sauerbruch. The Hume lecturer has given a lead in the application of means to ends in the practice of thoracic surgery. THE SMALL-POX
PROBLEM IN SWEDEN DURING the last few years the problems of small-pox and vaccination have been considered in Sweden in view of the occurrence there of cases of small-pox and the doubts raised by certain untoward incidents associated with vaccination both at home and abroad. These events were the subject of comment in the Swedish Riksdag as well as in the press, and in 1930 1 Jour. Amer. Med. Assoc., Feb. 4th, p. 315. 2 Arch. Méd.-Chir. de l’Appareil Respiratoire, 1932, Nos. 5 and 6.