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FOOD-POISONING DUE TO CLOSTRIDIUM WELCHII
938 assembled at the East Suffolk and Ipswich Hospital a splendid collection of pædiatric cases, medical, surgical, and orthopaedic. As a visitor remarked, the presentation was up to the best teaching hospital standards. The welcome opportunity for an exchange of views and the interest of this model meeting were an example of a combination which we commend to other societies who would like to travel. The practice of medicine, and especially general practice, has a habit of taking up weekends and interfering with excursions of this kind ; but Ipswich’s clinical society has shown that there are considerable advantages in resisting such interference. RECTAL ABSORPTION OF CHLORAMPHENICOL
IN this issue Dr. El Ramli, of Cairo, describes the of typhoid and paratyphoid fevers with chloramphenicol, which he administered rectally to some of the patients. The antibiotic was given by this route to infants, young children, patients who were vomiting or unable to swallow, and those who were uncooperative. The dosage was 50 mg. per kg. body-weight daily, divided into two, three, or four doses. According to El Ramli, chloramphenicol was as effective when given rectally as when given orally ; the average duration of fever with administration by either route was about 3 days. Dr. El Borolossy, also working in Cairo, examined the blood levels of chloramphenicol 12 hours after rectal administration of the drug. He states that with a dose of 25 mg. per kg. body-weight the serum-chloramphenicol level reached a high level within an hour and then declined rapidly in the 2nd to the 4th hours. Between the 4th and 12th hours the serum-chloramphenicol curves after rectal and after oral administration were close together. According to El Borolossy, concentrations inhibitory to susceptible organisms were obtained in the serum up to 12 hours after oral or rectal administration of 17-25 mg. of chloramphenicol per kg. body-weight. These observations do not agree with those of Roy and his colleagues,! of Toronto. These workers administered perforated capsules of chloramphenicol rectally to convalescent infants and children. In some cases the capsules were not retained ; but when they were retained the blood levels were disappointing. With doses of 55 mg. per kg. body-weight the absorption of the antibiotic was irregular, and sometimes none could be detected in the serum 4 hours after administration ; and even when it was given 4-hourly, the blood levels did not rise above 7 µg. per ml. After oral administration the blood levels ranged from 10 to 420 µg. per ml. The rectal dosage, already large, could not be increased, owing to the difficulty of retention. Because rectal absorption was so irregular and produced such low levels, Roy and his colleagues concluded that this method of administration is of dubious value. Kelly et a1.,2 of Philadelphia, report similar experiences. They found that the blood level after rectal administration was only about a fifth of that after oral administration of the same dose (22-24 mg. per kg. body-weight). The blood levels were more consistent after oral administration. Absorption from the rectum appeared to take longer than absorption from the upper part of the gut ; after rectal administration there was little change in the blood level for as long as 6 hours. Thus it seems that there is little to recommend the rectal use of chloramphenicol. Absorption is uncertain ; a larger dose of this expensive drug is needed ; and possibly proctitis and perineal dermatitis may result. If for any reason the antibiotic cannot be given by mouth, it can be administered by intramuscular injection dissolved in acetyl dimethylamine. treatment
1. Roy, T. E., Krieger, E., Craig, G., Cohen, D., McNaughten, G. A., Silverthorne, N. Antibiotics chemother. 1952, 2, 505. 2. Kelly, R. S., Hunt, A. D., Tashman, S. G. Pediatrics, 1951, 8, 362.
COMMITTEE ON N.H.S. COSTS Mr. lain Macleod has now chosen the people who are to meet under the chairmanship of Mr. C. W. Guillebaud. the Cambridge economist, to review the present and prospective cost of the National "
suggest means, whether by modifications otherwise, of ensuring the most effective
Health Service ; to in
organisation
or
control and efficient use of such Exchequer funds as may be made available ; to advise how, in view of the burdens on the Exchequer, a rising charge upon it can be avoided, while providing for the maintenance of an adequate Service ; and to make recommendations."
Invitations to serve on the committee have been accepted by Mr. J. W. Cook, D.SC., F.R.S., regius professor of chemistry in the University of Glasgow ; Sir Geoffrey Vickers, a member of the National Coal Board and of the Medical Research Council; and Sir John Maude, secretary to the Ministry of Health from 1940 to 1945 and later deputy chairman of the Local Government Boundary Commission. Mr. Macleod also invited the Trades Union Congress to nominate a member, and the T.U.C. have chosen Miss B. A. Godwin, a member of their council and assistant general secretary of the Clerical and Administrative Workers Union.
v.c.,
FOOD-POISONING
DUE TO WELCHII
CLOSTRIDIUM
food-poisoning may arise by multiplication bacteria-usually of the salmonella group-in the intestine, or by ingestion of toxic bacterial products, such as those produced by certain staphylococci. Among the organisms which have been suspected, but not convicted, of causing food-poisoning is Clostridium welchii. This was isolated from the faeces of patients in outbreaks described by Klein. Many years later McClung2 described three BACTERIAL
of
outbreaks in which Cl. welchii was isolated from the a volunteer who ate a sample of the food contaminated with this organism developed typical symptoms. The important study by Hobbs et al.3 makes it clear that we must now include OZ. welchii among the proven causes of food-poisoning. The outbreaks studied by Hobbs and by previous workers have shown that the usual foods infected with this organism are dishes containing meat which has been cooked, allowed to cool, then eaten either cold or reheated on the following day. Stewed, braised, or boiled meats are particularly liable to cause the disease. The clinical picture is fairly definite. Diarrhoea and abdominal pain begin after an incubation period of 8-20 hours; the patient rarely complains of nausea and vomiting, in contrast with staphylococcal food-poisoning. Salmonella food-poisoning almost invariably produces a rise in temperature, whereas Cl. welchii never causes pyrexia. The disease is usually mild, with recovery in about 24 hours ; but some old people have succumbed to it. The 01. welchii responsible for this disorder shows certain peculiarities. On primary isolation the colony is small and is non-haemolytic, though faint hæmolysis may develop after some days’ incubation. The organisms are relatively heat-resistant ; the spores have withstood boiling in foods for 2-3 hours, and in laboratory experiments for 5 hours. Experimental work by and Warrack4 has shown that these heat-resistant strains of Cl. welchii produce only small amounts of the recognised clostridial toxins ; and these workers believe that the strains should be classified as heat-resistant strains of Cl. welchii type A. The organism can be isolated from the faeces of most of the patients affected. Hobbs
food, and
Oakley
1. Klein, E. Zbl. Bakt. 1895, 18, 737. 2. McClung, L. S. J. Bact. 1945, 50, 229. 3. Hobbs, B. C., Smith, M. E., Oakley, C. L.. Warrack, G. H., Cruickshank. J. C. J. Hyg., Camb. 1953, 51, 75. 4. Oakley, C. L., Warrack, G. H. Ibid, p. 102.
939 isolated them from 89-9% of these patients, but from only 2.2% of normal persons. In a study of animal faeces the organism was rarely isolated from bovines but not imcommonly from pigs, rats, and mice. It was also isolated from fresh meat (except lamb) and from blowflies. Volunteers developed mild food-poisoning after cultures of Ol. welchii which had been isolated from contaminated meat, but it was uncertain whether the disease was due to a toxin alone, or to the ingestion of vegetative organisms. There seems little doubt that this type of foodpoisoning, like others, could be eliminated by good hygiene. Once more the dangers of eating precooked foods, kept a long time in conditions suitable for bacterial multiplication, have been demonstrated.
eating
TEN NUFFIELD YEARS TEN years ago Lord Nuffield, having set up and munificently endowed the foundation which bears his name, charged it with the task of advancing health and social well-being. Its work is thus one in which In we should all like to take a hand and an interest. its progress report1 the foundation describes itself as "aprivate fund serving the community," and it has certainly made good use of the opportunities offered by its amateur status. As a discerning pioneer it has been quick to foster schemes likely to be of public benefit but not yet sufficiently established to have won official support, and it has generously backed workers engaged in promising but admittedly speculative research. Over the ten years, 1943-53, the foundation’s total income has been £5 million, of which it has spent nearly £4 million. £786,000 has been given to medical work (including £229,000 for rheumatism) ; £347,000 to biological research ; £560,000 to research in physics ; £463,000 to the social sciences ; S32,000 to agriculture ; £925,000 to the care of old people ; and £831,000 to fellowships and scholarships. During the second half of the period the emphasis of the programmes for medical work shifted from particular specific diseases (with the exception of rheumatism) to normal health. Thus it has made grants of n67,220 to promote teaching and research in child health. The largest grant (£100,000) was spent on the establishment of an institute of child health in the University of London. Industrial health has also claimed its support, and £150,000 was given to establish departments of industrial health in the universities of Durham, Glasgow, and Manchester, and over f,15,000 to set up a working model for an industrial health service on the Slough trading-estate. Disquieted by the Teviot report on the unsatisfactory state of the nation’s teeth, the foundation also decided to encourage postgraduate teaching and research in dental health, and it has made grants totalling £90,000 to the dental schools in the universities of Durham, Leeds, and Manchester and at
Guy’s Hospital. The chronic rheumatic diseases cost the community dearly in health and distress that the foundation felt in singling out this group of diseases for special attention. Accordingly in 1947 it financed a pioneer centre at Manchester for the study of rheumatic diseases. The following year the management of the Oliver Bird Fund of £450,000 for the study and alleviation of rheumatism was entrusted to the foundation. Since 1947 it has financed much chemical work aimed at the total synthesis of cortisone and corticotropin (A.C.T.H.). The founda.tion’s keen eye for the future has also ranged purposefully over the biological sciences, and its eclectic help has been offered to workers studying such diverse topics as cellular biology, micro-organisms, comparative endocrinology, immunology, and neurophysiology. A
so
justified
1.
part of the report, which is to appear shortly, will describe the allocation of grants and fellowships in more detail. second
THE SMALL-LIST DOCTOR DISSATISFIED with the prospects for the small-list general practitioner under the distribution scheme which came into operation on April 1, a group of members of the British Medical Association made requisition in March for an extraordinary general meeting of the association ; and this meeting was held on May 5. The resolution before the meeting was : ’
That the Association being concerned by the modification of the present method of remuneration by capitation fees agreed in the Working Party’s report requires the Council forthwith to approach the Minister of Health with proposals for the better protection (financial and otherwise) of the small-list doctor and of the doctor newly seeking entry into practice, and requests the Minister of Health not to implement the Working Party’s report until the scheme for distribution of remuneration has been considered in the light of such proposals, and meanwhile to continue the present method of payment.
In proposing this resolution, Dr. W. J. Grant claimed that for the small-list man and the newly entered practitioner the Working Party’s distribution scheme was tantamount to direction of labour by economic pressurea device which no Government would have dreamed of using against the humblest member of a trade union. A practitioner’s inescapable expenses were identical -whether his list was 500 or 1500 ; and in Dr. Grant’s view the present scheme paid little regard to this fact. He suggested loading the capitation fee for the first 1500 patients-say, 8s. a head for the first 500 and 6s. for the next 1000-as a means of remedying this " inexcusable
injustice." The chairman of the General Medical Services Com-
mittee, Dr. A. Talbot Rogers, explained that his
com-
mittee had found it impossible to propose an immediate plan to offset the difficulties of the small practice, because they would know neither the size of the problem nor the amount of money available to solve it until the effects of the new distribution scheme had been observed. It was simple enough to find out which doctors had small lists, but the reasons for the small lists were much more complicated. To enable the facts to be collected and the results of the new scheme to be analysed, the Working Party had been recalled and had already begun its discussions. Preliminary figures for March and April indicated that the number of principals in general practice was increasing in the way that the Working Party had hoped, and that the consequent gain to the central pool would be more than enough to provide for cases of hardship among small-list and newly established practitioners. Dr. Talbot Rogers thought that hardship was not so widespread as many people believed, but he assured the meeting that now the necessary information was becoming available a satisfactory answer would be found. The meeting readily accepted this assurance and confirmed by a very large majority the approval given to the Working Party’s plan by the association’s Representative Body in Dublin last July. It is easy to understand the impatience of those doctors who may be in real difficulties under the new method of distribution ; but it is equally clear that any changes based on uncertain evidence would lead only to further dissatisfaction. At all events, the meeting made it clear that these difficulties are certainly being tackled - and in a sensible way-which is no doubt what those who asked for the meeting wanted to know.
Sir ROBERT ARCHIBALD, professor of bacteriology and in the Farouk University, Alexandria, and former director of Wellcome Tropical Research LaboraNuffield Foundation : Review of the First Ten Years, 1943-53. a tory in Khartoum and the Stack Medical Laboratory, Copies are obtainable from Nuffield Lodge, Regent’s Park, died on May 2 at the age of 73. London, N.W.1.
parasitology
IN this issue Dr. El Ramli, of Cairo, describes the of typhoid and paratyphoid fevers with chloramphenicol, which he administered rectally to some of the patients. The antibiotic was given by this route to infants, young children, patients who were vomiting or unable to swallow, and those who were uncooperative. The dosage was 50 mg. per kg. body-weight daily, divided into two, three, or four doses. According to El Ramli, chloramphenicol was as effective when given rectally as when given orally ; the average duration of fever with administration by either route was about 3 days. Dr. El Borolossy, also working in Cairo, examined the blood levels of chloramphenicol 12 hours after rectal administration of the drug. He states that with a dose of 25 mg. per kg. body-weight the serum-chloramphenicol level reached a high level within an hour and then declined rapidly in the 2nd to the 4th hours. Between the 4th and 12th hours the serum-chloramphenicol curves after rectal and after oral administration were close together. According to El Borolossy, concentrations inhibitory to susceptible organisms were obtained in the serum up to 12 hours after oral or rectal administration of 17-25 mg. of chloramphenicol per kg. body-weight. These observations do not agree with those of Roy and his colleagues,! of Toronto. These workers administered perforated capsules of chloramphenicol rectally to convalescent infants and children. In some cases the capsules were not retained ; but when they were retained the blood levels were disappointing. With doses of 55 mg. per kg. body-weight the absorption of the antibiotic was irregular, and sometimes none could be detected in the serum 4 hours after administration ; and even when it was given 4-hourly, the blood levels did not rise above 7 µg. per ml. After oral administration the blood levels ranged from 10 to 420 µg. per ml. The rectal dosage, already large, could not be increased, owing to the difficulty of retention. Because rectal absorption was so irregular and produced such low levels, Roy and his colleagues concluded that this method of administration is of dubious value. Kelly et a1.,2 of Philadelphia, report similar experiences. They found that the blood level after rectal administration was only about a fifth of that after oral administration of the same dose (22-24 mg. per kg. body-weight). The blood levels were more consistent after oral administration. Absorption from the rectum appeared to take longer than absorption from the upper part of the gut ; after rectal administration there was little change in the blood level for as long as 6 hours. Thus it seems that there is little to recommend the rectal use of chloramphenicol. Absorption is uncertain ; a larger dose of this expensive drug is needed ; and possibly proctitis and perineal dermatitis may result. If for any reason the antibiotic cannot be given by mouth, it can be administered by intramuscular injection dissolved in acetyl dimethylamine. treatment
1. Roy, T. E., Krieger, E., Craig, G., Cohen, D., McNaughten, G. A., Silverthorne, N. Antibiotics chemother. 1952, 2, 505. 2. Kelly, R. S., Hunt, A. D., Tashman, S. G. Pediatrics, 1951, 8, 362.
COMMITTEE ON N.H.S. COSTS Mr. lain Macleod has now chosen the people who are to meet under the chairmanship of Mr. C. W. Guillebaud. the Cambridge economist, to review the present and prospective cost of the National "
suggest means, whether by modifications otherwise, of ensuring the most effective
Health Service ; to in
organisation
or
control and efficient use of such Exchequer funds as may be made available ; to advise how, in view of the burdens on the Exchequer, a rising charge upon it can be avoided, while providing for the maintenance of an adequate Service ; and to make recommendations."
Invitations to serve on the committee have been accepted by Mr. J. W. Cook, D.SC., F.R.S., regius professor of chemistry in the University of Glasgow ; Sir Geoffrey Vickers, a member of the National Coal Board and of the Medical Research Council; and Sir John Maude, secretary to the Ministry of Health from 1940 to 1945 and later deputy chairman of the Local Government Boundary Commission. Mr. Macleod also invited the Trades Union Congress to nominate a member, and the T.U.C. have chosen Miss B. A. Godwin, a member of their council and assistant general secretary of the Clerical and Administrative Workers Union.
v.c.,
FOOD-POISONING
DUE TO WELCHII
CLOSTRIDIUM
food-poisoning may arise by multiplication bacteria-usually of the salmonella group-in the intestine, or by ingestion of toxic bacterial products, such as those produced by certain staphylococci. Among the organisms which have been suspected, but not convicted, of causing food-poisoning is Clostridium welchii. This was isolated from the faeces of patients in outbreaks described by Klein. Many years later McClung2 described three BACTERIAL
of
outbreaks in which Cl. welchii was isolated from the a volunteer who ate a sample of the food contaminated with this organism developed typical symptoms. The important study by Hobbs et al.3 makes it clear that we must now include OZ. welchii among the proven causes of food-poisoning. The outbreaks studied by Hobbs and by previous workers have shown that the usual foods infected with this organism are dishes containing meat which has been cooked, allowed to cool, then eaten either cold or reheated on the following day. Stewed, braised, or boiled meats are particularly liable to cause the disease. The clinical picture is fairly definite. Diarrhoea and abdominal pain begin after an incubation period of 8-20 hours; the patient rarely complains of nausea and vomiting, in contrast with staphylococcal food-poisoning. Salmonella food-poisoning almost invariably produces a rise in temperature, whereas Cl. welchii never causes pyrexia. The disease is usually mild, with recovery in about 24 hours ; but some old people have succumbed to it. The 01. welchii responsible for this disorder shows certain peculiarities. On primary isolation the colony is small and is non-haemolytic, though faint hæmolysis may develop after some days’ incubation. The organisms are relatively heat-resistant ; the spores have withstood boiling in foods for 2-3 hours, and in laboratory experiments for 5 hours. Experimental work by and Warrack4 has shown that these heat-resistant strains of Cl. welchii produce only small amounts of the recognised clostridial toxins ; and these workers believe that the strains should be classified as heat-resistant strains of Cl. welchii type A. The organism can be isolated from the faeces of most of the patients affected. Hobbs
food, and
Oakley
1. Klein, E. Zbl. Bakt. 1895, 18, 737. 2. McClung, L. S. J. Bact. 1945, 50, 229. 3. Hobbs, B. C., Smith, M. E., Oakley, C. L.. Warrack, G. H., Cruickshank. J. C. J. Hyg., Camb. 1953, 51, 75. 4. Oakley, C. L., Warrack, G. H. Ibid, p. 102.
939 isolated them from 89-9% of these patients, but from only 2.2% of normal persons. In a study of animal faeces the organism was rarely isolated from bovines but not imcommonly from pigs, rats, and mice. It was also isolated from fresh meat (except lamb) and from blowflies. Volunteers developed mild food-poisoning after cultures of Ol. welchii which had been isolated from contaminated meat, but it was uncertain whether the disease was due to a toxin alone, or to the ingestion of vegetative organisms. There seems little doubt that this type of foodpoisoning, like others, could be eliminated by good hygiene. Once more the dangers of eating precooked foods, kept a long time in conditions suitable for bacterial multiplication, have been demonstrated.
eating
TEN NUFFIELD YEARS TEN years ago Lord Nuffield, having set up and munificently endowed the foundation which bears his name, charged it with the task of advancing health and social well-being. Its work is thus one in which In we should all like to take a hand and an interest. its progress report1 the foundation describes itself as "aprivate fund serving the community," and it has certainly made good use of the opportunities offered by its amateur status. As a discerning pioneer it has been quick to foster schemes likely to be of public benefit but not yet sufficiently established to have won official support, and it has generously backed workers engaged in promising but admittedly speculative research. Over the ten years, 1943-53, the foundation’s total income has been £5 million, of which it has spent nearly £4 million. £786,000 has been given to medical work (including £229,000 for rheumatism) ; £347,000 to biological research ; £560,000 to research in physics ; £463,000 to the social sciences ; S32,000 to agriculture ; £925,000 to the care of old people ; and £831,000 to fellowships and scholarships. During the second half of the period the emphasis of the programmes for medical work shifted from particular specific diseases (with the exception of rheumatism) to normal health. Thus it has made grants of n67,220 to promote teaching and research in child health. The largest grant (£100,000) was spent on the establishment of an institute of child health in the University of London. Industrial health has also claimed its support, and £150,000 was given to establish departments of industrial health in the universities of Durham, Glasgow, and Manchester, and over f,15,000 to set up a working model for an industrial health service on the Slough trading-estate. Disquieted by the Teviot report on the unsatisfactory state of the nation’s teeth, the foundation also decided to encourage postgraduate teaching and research in dental health, and it has made grants totalling £90,000 to the dental schools in the universities of Durham, Leeds, and Manchester and at
Guy’s Hospital. The chronic rheumatic diseases cost the community dearly in health and distress that the foundation felt in singling out this group of diseases for special attention. Accordingly in 1947 it financed a pioneer centre at Manchester for the study of rheumatic diseases. The following year the management of the Oliver Bird Fund of £450,000 for the study and alleviation of rheumatism was entrusted to the foundation. Since 1947 it has financed much chemical work aimed at the total synthesis of cortisone and corticotropin (A.C.T.H.). The founda.tion’s keen eye for the future has also ranged purposefully over the biological sciences, and its eclectic help has been offered to workers studying such diverse topics as cellular biology, micro-organisms, comparative endocrinology, immunology, and neurophysiology. A
so
justified
1.
part of the report, which is to appear shortly, will describe the allocation of grants and fellowships in more detail. second
THE SMALL-LIST DOCTOR DISSATISFIED with the prospects for the small-list general practitioner under the distribution scheme which came into operation on April 1, a group of members of the British Medical Association made requisition in March for an extraordinary general meeting of the association ; and this meeting was held on May 5. The resolution before the meeting was : ’
That the Association being concerned by the modification of the present method of remuneration by capitation fees agreed in the Working Party’s report requires the Council forthwith to approach the Minister of Health with proposals for the better protection (financial and otherwise) of the small-list doctor and of the doctor newly seeking entry into practice, and requests the Minister of Health not to implement the Working Party’s report until the scheme for distribution of remuneration has been considered in the light of such proposals, and meanwhile to continue the present method of payment.
In proposing this resolution, Dr. W. J. Grant claimed that for the small-list man and the newly entered practitioner the Working Party’s distribution scheme was tantamount to direction of labour by economic pressurea device which no Government would have dreamed of using against the humblest member of a trade union. A practitioner’s inescapable expenses were identical -whether his list was 500 or 1500 ; and in Dr. Grant’s view the present scheme paid little regard to this fact. He suggested loading the capitation fee for the first 1500 patients-say, 8s. a head for the first 500 and 6s. for the next 1000-as a means of remedying this " inexcusable
injustice." The chairman of the General Medical Services Com-
mittee, Dr. A. Talbot Rogers, explained that his
com-
mittee had found it impossible to propose an immediate plan to offset the difficulties of the small practice, because they would know neither the size of the problem nor the amount of money available to solve it until the effects of the new distribution scheme had been observed. It was simple enough to find out which doctors had small lists, but the reasons for the small lists were much more complicated. To enable the facts to be collected and the results of the new scheme to be analysed, the Working Party had been recalled and had already begun its discussions. Preliminary figures for March and April indicated that the number of principals in general practice was increasing in the way that the Working Party had hoped, and that the consequent gain to the central pool would be more than enough to provide for cases of hardship among small-list and newly established practitioners. Dr. Talbot Rogers thought that hardship was not so widespread as many people believed, but he assured the meeting that now the necessary information was becoming available a satisfactory answer would be found. The meeting readily accepted this assurance and confirmed by a very large majority the approval given to the Working Party’s plan by the association’s Representative Body in Dublin last July. It is easy to understand the impatience of those doctors who may be in real difficulties under the new method of distribution ; but it is equally clear that any changes based on uncertain evidence would lead only to further dissatisfaction. At all events, the meeting made it clear that these difficulties are certainly being tackled - and in a sensible way-which is no doubt what those who asked for the meeting wanted to know.
Sir ROBERT ARCHIBALD, professor of bacteriology and in the Farouk University, Alexandria, and former director of Wellcome Tropical Research LaboraNuffield Foundation : Review of the First Ten Years, 1943-53. a tory in Khartoum and the Stack Medical Laboratory, Copies are obtainable from Nuffield Lodge, Regent’s Park, died on May 2 at the age of 73. London, N.W.1.
parasitology