- Email: [email protected]
ON STREPTOCOCCAL INFECTIONS OF SEPTIC WOUNDS AT A BASE HOSPITAL.
MR. FLEMING & DR. PORTEOUS : STREPTOCOCCAL INFEOTIONS OF WOUNDS.
alteration, if any, would result from prolonged cultivation on artificial media, the strains which showed the widest variaAs mentioned grown on agar slopes, sealed with paraffin wax, and placed in the icechest. They were subsequently subcultured on to further agar slopes at intervals of six weeks, the fresh cultures, after 24 hours in the incubator, being preserved in the same way. The original strain was tested on five batches of mice On the first between July, 1918, and February, 1919. occasion no mouse succumbed within 30 days. In the later experiments a few mice died in each case. The highest mortality occurred in the last test carried out, when four of eight mice died during the 30 days over which the experiment continued. From only one of these mice, however, was B. Daitysz isolated. Moreover, the deaths, when they occurred, were irregularly distributed in time. On no occasion were more than one mouse found dead on any one day. The strain from the spleen of the mouse of Experiment 3 D which was used in Experiment 4 A was retested on four subsequent occasions between September, 1918, and February, 1919. In the first experiment 8 of 12 mice died within 30 days, a mortality of 66 per cent. In the second experiment the mortality during the same period was 100 per cent. In the three subsequent tests the mortality was 66, 66, and 62 per cent. respectively. Moreover, there was a most definite time distribution. In each of the three earlier experiments there was an incubation period of 12 to 15 days, followed by an outbreak involving the death of a large proportion of the mice within a few days. The difference between the results of these experiments and those carried out with the original strain were most striking when actually observed. On the last two occasions on which this strain was tested the tendency to produce a series of deaths within a short time interval and following a definite incubation period seemed to have been lost. Similarly, the strain labelled Spleen 3 : 5 x : 9.12," which was employed in Experiment 6 x 7, was retested on It three occasions within the following two months. showed on the first three occasions a consistent tendency to produce a high and early mortality. Thus all the mice of the first experiment died within three days. All the mice of the second experiment succumbed on the 6th day. Four of six mice fed in the third experiment died on the 3rd day, while a fifth died on the 16th. On the last retesting this strain seemed to have lost its peculiar properties. Two other strains which had shown particularly low pathogenicity were subsequently retested, and the results confirmed those originally obtained. Thus two strains at least were evolved which pOflsessed quite definite infective properties. One tended to produce an outbreak of disease after an incubation period of 12 to 15 days. The other led to the death of all the animals fed within a few days. These properties were maintained for weeks or months under artificial cultivation, but were gradually lost, and when finally tested the strains were indistinguishab!e from the original strain of B. Danysz. No attempt was made to maintain the pathogenicity of the cultures by special methods of cultivation and storage. The exact combination of properties on which this pathogenicity depended was a subject for surmise, but it was clearly not simply a question of virulence in the strict conventional sense. It seemed better, therefore, to rely on the simplest methods of culture and observe any changes which occurred. The results of observations on the factors possibly concerned in the loss of pathogenicity by passage, and especially on the question of the spread of the infection from the mice fed on cultures of the bacillus to their normal companions, will be considered in my last lecture. Bibliography.—Bainbridge : Journ. Path. and Bact., 1909, xiii., 443. Billet, le Bihan and others: Arch. de Méd. et de Pharm. Milit., 1910, lv., 259. Brownlee: Trans. Roy. Soc. Med. (Epidem. Soc.), 1909, ii., 243. Bruns and Höhn: Kiin. Jahrb., 1908, xviii., 285. Butler: Proc. Roy. Soc. Med. (Epidem. Sec.), 1909. ii., 59. Chesney: Journ. Exp. Med., 1916, xxiv., 387. Danysz: Ann. de l’Inst. Pasteur, 1900, xiv., 193. Flack: Med. Res. Comm. Spec. Rept., Ser. No. 3.1917. Glover: Journ. Hyg., 1918, xvii., 350, 367. Graham-Smith : The Bacteriology of Diphtheria, Camb., 1908. Hutchens : Med. Res. Comm. Rept., 1916. Johnston: Med. Res. Comm. Kept., 1916. Köber: Zeitschr. f. Hyg., 1899, xxxi., 433. Ledingham and Arkwright: The Carrier Problem in Infectious Diseases, Lond., 1912. Ledingham and Penfold: Journ. of Hyg., 1914, xiv., 242. Liston: Rep. Bombay Bact. Lab., 1907. Mühlens, Dahm, and Fürst : Centralb. f. Bakter. ü Parasitenk, 1909, Orig., xlviii., 1. Penfold: Journ. Hyg., 1914, xiv., 215. Stillman: Journ. Exp. Med., 1917, xxvi., 513. Wadsworth and Kirkbride: Journ. Exp. Med., 1918, xxviii., 791.
tions
were
retested at
subsequent
above, the various strains isolated
dates.
were
49
ON
STREPTOCOCCAL INFECTIONS OF SEPTIC WOUNDS AT A BASE HOSPITAL. BY
ALEXANDER FLEMING,
F.R.C.S.
ENG.,
PROFESSOR, ROYAL COLLEGE OF SURGEONS OF ENGLAND;
HUNTERIAN
AND
A. B. PORTEOUS, M.B., B.S. LOND., LATE
PATHOLOGISTS TO NO.
8
STATIONARY HOSPITAL, B.E.F., FRANCE.
IN connexion with streptococcus infections of wounds at base hospitals there are certain questions which are of fundamental importance. What
are the Types of Streptooocoi that Require to be Seriously Considered i7a Wonnd Infeotions? ? There is one type of streptococcus which is predominant in septic wounds at the base. This type is responsible for almost all the severe septic complications of these wounds.
It is to be found in pure culture in
nearly
all the infected
joint cavities and fresh pockets of the wounds, and in our experience it has been responsible for all the streptococcal septicaemia following septic wounds. Oharaoters of this streptooOOotlS.-It grows in broth in long chains of regular cocci. Some strains after 24 hours show very marked involution forms, the cocci being all shapes and sizes. The culture in broth consists of small woolly masses, which settle to the bottom of the tube (or along the side of the tube if it is incubated in a slanting position), leaving the upper portion of the medium clear. On agar (Douglas’s trypsin agar) it grows well in moderate-sized colonies, which show by transmitted light a definite dark central portion, while the edges are slightly wavy and irregular. It does not liquefy gelatin. This streptococcus always grows better anaerobically, and not infrequently when first isolated it will not grow aerobically. After being cultivated for a short time, however, it grows freely under aerobic conditions, It is not constant in its sugar reactions. In the great majority cases it ferments glucose, lactose, saccharose, and salicin, raffinose, mannite, or inulin, A few strains, however but not 12 (about per cent.), ferment mannite. These mannite-
of
strains are identical morphologically with the non-mannite fermenters, and it has been shown by Douglas, Colebrook, and Fleming, in a report to the Medical Research Committee not yet published, by means of agglutination and absorption tests that serologically they are also identical. Clotting of milk.-This test is very inconstant, and we bave found that as regards the clotting of milk with these streptococci very much depends on the size of the tube in which the test is carried out. If the tube is of large size then the clotting is always delayed and it may even not take place in ten days, whereas in a small test-tube there is definite clotting in 24 hours. In a series of tubes of different sizes containing milk which had been heavily implanted with Strepto6oeo?ts pyogenes and incubated for five days it was observed that no clotting had occurred in the two largest tubes, in the third tube clotting had occurred but there was no contraction of the clot, while in the smallest tube there was firm clotting with much contraction of the clot. This clotting of the milk in the smallest tube had occurred in the first 24 hours. Even in small tubes, however, the clotting of milk by Streptococcus pyogents is quite inconstant and is worthless as a
fermenting
test.
the strains of this streptococcus power, but there seemed to be enormous differences in the amount of h2emolysin produced under the same conditions by streptococci which were isolated from the blood of septicasmic patients. In a number of cases the hsemolytio power was tested by centrifuging a broth culture and incubating for two hours at 370 C. dilutions of the clear supernatant fluid with washed human red corpuscles. In most cases, however, the question of whether these streptococci were hsemolytio or not was tested ty noting the appearance produced by their growth on a blood agar plate (see Fig. 2). InoidenOB of this stre ptococcus.-In a series of over 100 septic wounds (fractured femurs) which had remained at a base hospital for over seven days this streptococcus was present in almost every one. In cases of a similar nature where streptococci were recovered from the blood (47 cases) the organism was invariably of this type B 2
Haemolytio pomer.-All some hasmolytic
showed
50 ls the "Haemolytio" Charaoter of the Streptoaooeus of the characteristic colour of the discharges. Other organisms which spread around a wa’’d in the same way are B. proteus Fundamental Importance-i.e., Can Non-haemol.’ltio Streptoand diphtheroid bacilli. Now, as the 8treptooooous pyogenes ooooi be Ignored for Praatioal Purposes in Wozcnds?? As has been stated above, the only streptococcus which will grow in the discharges very much more readily than will these other organisms, it would be a miracle if it were we have found to give rise to serious complications in a spread in the same way. It is unfortunate that infection wound is the "pyogenes"type, which. belongs to the does not produce any characteristic change by streptococcus to of and we were forced haemolytic group streptococci, the smell or colour of the discharges, as it does not consider the non-haemoiytic streptococci to be of only obtrude itself on the notice of the surgeon until some secondary importance. In the more recent wounds, and serious complication arises. in had which gas gangrene especially in the wounds developed, there is to be found very freqaently streptococci Have any Points Bearing on the Methods of Recovery from of the I I fmcalis " type. These are not present with anything Streptococcus InfeJtions Come to Light, and, if so, like the same frequency in the latter cases. One of us Can these be Exploited in Treatment ? (A..F.) in conjunction with Douglas and Colebrookshowed In cases of septicaemia following serious wounds the prothat streptococci (and other organisms) had a powerful effect of recoveries is very small. Out of a series of in increasing the growth of anaerobic bacilli when grown portion 40 cases of septicæmia following compound fracture of the in tt be that these with them may streptococci femur we hive seen symbiosis. only four recoveries. The reason for of the " faecalis " type have some importance in the wound these recoveries is not very evident. All the patients who on account of this symbiotic action, but alone they do not recovered were treated with streptococcus vaccine, but it was seem to be of any importance in wounds at the base. very difficult to demonstrate in any of these septicaemia cases 3 What is the ’SCM7’(M of the Streptoooooi F01fY/d in W011,nds? ? any direct benefit from the vaccine. Examinations at a C.C.S. on recently inflicted wounds In some cases of pyaemia, however, and in many less severe have shown that in only about 15 per cent. of cases is cases, the administration of streptococcus vaccine in doses pyogenes present. Examinations at the base inof 1,000,000 to 5,000,000 was repeatedly followed by a drop Streptneoceus in tne temperature ana a cases which have been in more than a week reveal feeling of well-being to the the presence of this organpatient. It has often been demonstrated that, followism in over 90 per cent. of the wounds. ing the injection of streptococcus vaccine, there is a During the summer of 1918 we rise in the amount of antiexamined a bodies in the blood. In number of the gauze packs removed from wounds on cases of severe injury, such arrival at the base. When as a fractured femur, there the patient had been kept are very often portions of at the C. C. S. for more than the wound which are inthree or four days Streptoefficiently drained and to eoccus pyogenes was present which the blood fluids do in almost every case. These not have access, and this cases correspond, therefore, militates against any very dramatic effect following closely with the patients who have been in base hosthe administration of vaccine in such cases. We pitals for more than a few hold a very strong opinion, days. Where, however, the however, that in all septic patient had been sent wounds where the surgeon straight on to the base after excision of the wound we secures good drainage no found that Streptooooous harm would be done and much good woald result pyogenes was present only in 15 out of 75;cases. Although from a routine administrain the majority of the packs tion of stock streptococcus from these recent cases we vaccine in doses of from failed to find Streptococcus 1,000,000 to 5,000,000 once a week. It is not practicable pyogenes, we were able to recover other microbes in to make autogenous vacPl%te culture of 1 c.cm. of blood from a septieasmio patient taken immecines in every case, and it every case from those porafter disturbed washed. Note the diately being by being large number tions of the packs which has been demonstrated by of streptococcus colonies and the zone of haemolysis around each. came from the depths Douglas, Colebrook, and of the wound, and often these microbes were present in very Fleming that when an animal is with one strain of large numbers. The microbes isolated in these cases were Streptococcus pyogenes it develops antibodies (agglutinins) to the same degree to all strains. It would appear, therefore, chiefly anaerobic and aerobic bacilli and staphylococci. It has been conclusively demonstrated that Streptoooe01J.S that a stock vaccine would be as useful as an autogenous one. In cases of septicæmia it seems much more likely that pyogenes will grow much better than these other microbes in the blood fluids2 such as would be found in a recently streptococci are being continually thrown into the blood excised wound, so that had the streptococcus been present as stream from some septic focus than that they should actually a primary infection it should have been demonstrable on be growing and multiplying in the blood stream. If they arrival at the base. It is to be noted, therefore, that on did nourish in the circulating blood, then they should be arrival at the C. C. S. 15 per cent. of the men were infected present in much larger number than they are. If Ic.cm. of with 8streptococcus pyogenes,. on arrival at the base (when blood is taken from a septicasmic patient, mixed with liquid the cases had been sent straight on after operation) 20 per agar at 470 C., and plated, it is uncommon to get more than cent, were infected, but after a stay at the base of a week 100 colonies. Usually only two or three develop. This method has been found to be the best for blood over 90 per cent. were found to have Streptococcus pyogenes In quite a large series, of blood in their wounds. It would seem a warrantable deduction culture in such cases. from these observations that the streptococcal infection of cultures it has never failed to reveal streptococci when they wounds is in most cases a hospital infection, and it is were found in fluid cultures, and in two cases streptococci probable that in the dressing of the wound the infection is were found when they failed to develop from blood added to carried from one patient to another. remembered, however, that in a large series of puerIt has long been known that B. pyocyane2as is spread from 3 It should be cases in which streptococci were demonstrated in the peral septicaemia one patient to another in a ward by faulty technique in I blood Western (THE LANCET, 1912, i., 351) by the use of vaccines obtained a as this infection is manifest to naked the very high percentage of recoveries (45 as against about 10 dressing, in a control series not treated by vaccines). These puerperal septi1 THE cæmias do not seem to be very different from septicaemia following a LANCET, 1917, i., 604. 2 Wright: Proceedings of the Royal Society of Medicine, 1915. septic wound.
not
I in
injected
I
eye byB
DR. H. J. B. FRY : CERTAIN ORGANISMS ISOLATED FROM INFLUENZA CASES.
[
51
broth or glucose broth. It has also the great merit that the NOTE ON number of streptococci in the circulating blood can be CERTAIN ORGANISMS ISOLATED FROM determined. The technique is as follows :is case blood from the 1 c.cm. of CASES OF INFLUENZA. suspected septicaemio added to about 5 c.cm. of water. The blood will thus be BY H. J. B. FRY, M.D. OXON., laked and the clotting power diminished, so that it can readily be carried back to the laboratory before coagulation CAPTAIN, R.A.M.C. (T.). takes place- It is then mixed with about 20 c.cm. of agar at 47° C., poured into a Petri dish, allowed to set, and incubated. IN the course of investigation of material derived from In 24 hours the colonies can easily be seen. Minced meat medium, such as is commonly used in the cases of influenza during the three waves of the present cultivation of anaerobes, furnishes a better fluid medium for when searching for Pfeiffer’s bacillus, Gramblood culture in these surgical cases than does broth, glucose epidemic, "Pfeiffer-like" bacilli were frequently isolated. negative, broth, or citrated broth. In several cases we have obtained not, however, hasmophilic, and grew rapidly and growths of streptococcus from the blood in this medium They were They have been isolated from when they failed to develop in the broth cultures. It has readily on ordinary agar. the advantage that anaerobes, if present, will also develop. sputum, post-mortem material, and in blood culture. The The figure represents a plate made from 1 c.cm. of blood organisms derived from the latter source deserve further from a patient with septicaemia following a flesh wound in description. the thigh. It shows very many more streptococci than are I They were isolated from the blood of two German prisoners, out of four cases examined, at the commencement of the in the Two after blood. the usually present days specimen third wave of the epidemic in February, 1919. The camp was taken the patient died, and the autopsy showed, in addition to a septic thigh wound, abscesses in the hand, ’, to which the prisoners had belonged had escaped the two wrist, both elbows, neck, and a very large abscess in the previous waves, but was overwhelmed by the present one, a buttock. The specimen of blood was taken immediately the large proportion of the prisoners being severely attacked. The organism was obtained in 2 per cent. glucose broth, orderlies had finished washing the patient, during which and he must of have been disappeared in 24 hours in the blood culture, as round or necessity process considerably turbed, and it seems probable that the large number of oval Gram-negative " yeast-like " bodies, 3-5,u long by 2-4µ streptococci in the blood was due rather to this disturbance broad. Subculture to agar produced, not the above organisms but Gram-negative bacilli, varying in size from coccal or than to their growth in the blood stream. It is unlikely, also, that the small number of streptococci cocco-b3cillary forms to short filaments. The "yeast-like" present in the blood stream in the ordinary case of septi- bodies rapidly disappeared from the blood culture, and were caemia would be able to flourish in that situation, as the serum replaced by clumps of Gram-negative bacilli, in the neighof these patients show by Sir Almroth Wright’s sero-culture bourhood of which could be seen, in some cases, Grammethod a very much enhanced bactericidal power to Strepto- negative amorphous masses, resembling the ruptured envelopes " coccus pyogenes.4 (The bactericidal power of normal serum of the above-mentioned yeast-like" bodies. to this microbe is practically nil.) Chccraeters of Organism : Pathogenesis. So far as we know, streptococci are destroyed in the body The bacilli were pure in subculture, and had the by three agencies: (1) bactericidal power of the serum ; and cultural characters :(2) direct bactericidal power of the leucocytes (without morphological and cultural elearccoters.-Small non-sporing Morphology phagocytosis) ; (3) phagocytosis due to the combined action bacilli, often grouped in parallel, or as diplo-bacilli, 1-21-’ in of the serum (opsonic power) and leucocytes. In streptobut varying in size from coccal forms to short filacoccal septicaemia these are changed from the normal as length, ments. The smaller forms are actively, but the larger forms follows. are motile. They are Gram-negative but not acid1. Bactericidal power of the sercum. (This, as stated above. fast.feebly, Polar staining is not usually present. They are aerobic and grow rapidly and well on agar, forming a whitish-grey 2. Direct bactericidal power of the leucocytes.--It has been moist growth of circular, slightly flattened colonies, about shown5 that living leucocytes have the power of destroying 0’5 mm. in diameter. Viewed by transmitted light, the streptococci without ingesting them. This power of the colonies are translucent and slightly iridescent. In stableucocytes is apparently unaltered in septicaemia cases culture on gelatin there is a white growth, confined to the except that as there is always a leucocytosis in these cases needle track, without extension on the surface, and the the power is more manifest. is not liquefied. Broth is rendered turbid, with a 3. Phagoaytosis.-In some cases of septicæmia the serum gelatin whitish, stringy deposit. flocculent, has lost completely or almost completely its opsonic power The fermentation reactions are as follows: Acid pro(and also its complementing power). The phagocytic power duction but no gas in dextrose, maltose, and mannite. No of the leucocytes is not diminished. change in lactose, cane-sugar, salicin, or inulin. Litmus It would appear from these observations that, as a rule, it milk is first rendered faintly acid and then becomes strongly is not the circulating blood which is at fault in cases of without any clotting. Neutral-red broth is rendered alkaline, we have to alkaline. streptococcal septicaemia, and in all probability There is a fairly well-marked indol reaction after look for some deficiency in the local protective mechanism 48 hours’ growth in peptone water. Stalactite growth was which allows access of the streptococci to the blood stream. not obtained in butter-fat broth. It would seem to follow, also, that for the successful treatcent. salt agar, numerous yeast-like forms Grown on 6 ment of a case of septicaemia the most essential element were obtainedper those obtained in the blood resembling would be the thorough local treatment of the infected focus. with filamentous, curved, and swollen culture, together It has been observed that when an infection has become forms. The organism resists heating to 65° C. for 30 minutes, circumscribed by the collection of leucocytes in the walls but is killed at a temperature of 600 C. for 1 hour. of the wound and by the other factors which operate was highly pathogenic to the Pathogenesis.-The locally in this connexion, it is very difficult to graft a rat and guinea-pig. organism 0’25 c.cm. of a saline emulsion of a serious streptococcal infection on the wound. It follows 24-hour culture by intrathoracic injection killed a white from this that the utmost care should be taken in the first rat in 17agar hours. The lesions produced were ecchymoses and few days after the injury to keep out the streptococcus extravasations on the surfaces of both lungs, and to avoid any treatment which will inhibit the defensive hæmorrhagic The heart was which were congested and oedematous. processes developing. In the after-treatment fresh tissue engorged and filled with clot. The organism was recovered should only be opened up when there is a very urgent in pure culture from heart, lungs, and spleen. necessity. A similar dose by intrathoracic injection killed a guineaIn conclusion, we wish to express our thanks to Major M. in five days, causing a slight caseous nodule at the site Sinclair and our other surgical colleagues for permitting us pig of inoculation, sero-purulent effusions into both pleural sacs, to make observations on patients under their care ; to ar.d lobular pneumonia with haemorrhages in both lungs. Captain L. Colebrook for permission to use some of his The bronchial glands were greatly enlarged and showed experimental work ; and to the Medical Research Committee caseous nodules. The heart was dilated and filled with for supplying us with apparatus which made the work easier. clot. The organism was recovered in pure culture from the effasion, lungs, heart blood, tracheal mucus, and 4 For this observation we are indebted to pleural Captain L. Colebrook. spleen. By intraperitoneal inoculation death was caused 5 Wright, Fleming, and Colebrook, THE LANCET, 1918, i., 831.
following
is
increased.)
.
alteration, if any, would result from prolonged cultivation on artificial media, the strains which showed the widest variaAs mentioned grown on agar slopes, sealed with paraffin wax, and placed in the icechest. They were subsequently subcultured on to further agar slopes at intervals of six weeks, the fresh cultures, after 24 hours in the incubator, being preserved in the same way. The original strain was tested on five batches of mice On the first between July, 1918, and February, 1919. occasion no mouse succumbed within 30 days. In the later experiments a few mice died in each case. The highest mortality occurred in the last test carried out, when four of eight mice died during the 30 days over which the experiment continued. From only one of these mice, however, was B. Daitysz isolated. Moreover, the deaths, when they occurred, were irregularly distributed in time. On no occasion were more than one mouse found dead on any one day. The strain from the spleen of the mouse of Experiment 3 D which was used in Experiment 4 A was retested on four subsequent occasions between September, 1918, and February, 1919. In the first experiment 8 of 12 mice died within 30 days, a mortality of 66 per cent. In the second experiment the mortality during the same period was 100 per cent. In the three subsequent tests the mortality was 66, 66, and 62 per cent. respectively. Moreover, there was a most definite time distribution. In each of the three earlier experiments there was an incubation period of 12 to 15 days, followed by an outbreak involving the death of a large proportion of the mice within a few days. The difference between the results of these experiments and those carried out with the original strain were most striking when actually observed. On the last two occasions on which this strain was tested the tendency to produce a series of deaths within a short time interval and following a definite incubation period seemed to have been lost. Similarly, the strain labelled Spleen 3 : 5 x : 9.12," which was employed in Experiment 6 x 7, was retested on It three occasions within the following two months. showed on the first three occasions a consistent tendency to produce a high and early mortality. Thus all the mice of the first experiment died within three days. All the mice of the second experiment succumbed on the 6th day. Four of six mice fed in the third experiment died on the 3rd day, while a fifth died on the 16th. On the last retesting this strain seemed to have lost its peculiar properties. Two other strains which had shown particularly low pathogenicity were subsequently retested, and the results confirmed those originally obtained. Thus two strains at least were evolved which pOflsessed quite definite infective properties. One tended to produce an outbreak of disease after an incubation period of 12 to 15 days. The other led to the death of all the animals fed within a few days. These properties were maintained for weeks or months under artificial cultivation, but were gradually lost, and when finally tested the strains were indistinguishab!e from the original strain of B. Danysz. No attempt was made to maintain the pathogenicity of the cultures by special methods of cultivation and storage. The exact combination of properties on which this pathogenicity depended was a subject for surmise, but it was clearly not simply a question of virulence in the strict conventional sense. It seemed better, therefore, to rely on the simplest methods of culture and observe any changes which occurred. The results of observations on the factors possibly concerned in the loss of pathogenicity by passage, and especially on the question of the spread of the infection from the mice fed on cultures of the bacillus to their normal companions, will be considered in my last lecture. Bibliography.—Bainbridge : Journ. Path. and Bact., 1909, xiii., 443. Billet, le Bihan and others: Arch. de Méd. et de Pharm. Milit., 1910, lv., 259. Brownlee: Trans. Roy. Soc. Med. (Epidem. Soc.), 1909, ii., 243. Bruns and Höhn: Kiin. Jahrb., 1908, xviii., 285. Butler: Proc. Roy. Soc. Med. (Epidem. Sec.), 1909. ii., 59. Chesney: Journ. Exp. Med., 1916, xxiv., 387. Danysz: Ann. de l’Inst. Pasteur, 1900, xiv., 193. Flack: Med. Res. Comm. Spec. Rept., Ser. No. 3.1917. Glover: Journ. Hyg., 1918, xvii., 350, 367. Graham-Smith : The Bacteriology of Diphtheria, Camb., 1908. Hutchens : Med. Res. Comm. Rept., 1916. Johnston: Med. Res. Comm. Kept., 1916. Köber: Zeitschr. f. Hyg., 1899, xxxi., 433. Ledingham and Arkwright: The Carrier Problem in Infectious Diseases, Lond., 1912. Ledingham and Penfold: Journ. of Hyg., 1914, xiv., 242. Liston: Rep. Bombay Bact. Lab., 1907. Mühlens, Dahm, and Fürst : Centralb. f. Bakter. ü Parasitenk, 1909, Orig., xlviii., 1. Penfold: Journ. Hyg., 1914, xiv., 215. Stillman: Journ. Exp. Med., 1917, xxvi., 513. Wadsworth and Kirkbride: Journ. Exp. Med., 1918, xxviii., 791.
tions
were
retested at
subsequent
above, the various strains isolated
dates.
were
49
ON
STREPTOCOCCAL INFECTIONS OF SEPTIC WOUNDS AT A BASE HOSPITAL. BY
ALEXANDER FLEMING,
F.R.C.S.
ENG.,
PROFESSOR, ROYAL COLLEGE OF SURGEONS OF ENGLAND;
HUNTERIAN
AND
A. B. PORTEOUS, M.B., B.S. LOND., LATE
PATHOLOGISTS TO NO.
8
STATIONARY HOSPITAL, B.E.F., FRANCE.
IN connexion with streptococcus infections of wounds at base hospitals there are certain questions which are of fundamental importance. What
are the Types of Streptooocoi that Require to be Seriously Considered i7a Wonnd Infeotions? ? There is one type of streptococcus which is predominant in septic wounds at the base. This type is responsible for almost all the severe septic complications of these wounds.
It is to be found in pure culture in
nearly
all the infected
joint cavities and fresh pockets of the wounds, and in our experience it has been responsible for all the streptococcal septicaemia following septic wounds. Oharaoters of this streptooOOotlS.-It grows in broth in long chains of regular cocci. Some strains after 24 hours show very marked involution forms, the cocci being all shapes and sizes. The culture in broth consists of small woolly masses, which settle to the bottom of the tube (or along the side of the tube if it is incubated in a slanting position), leaving the upper portion of the medium clear. On agar (Douglas’s trypsin agar) it grows well in moderate-sized colonies, which show by transmitted light a definite dark central portion, while the edges are slightly wavy and irregular. It does not liquefy gelatin. This streptococcus always grows better anaerobically, and not infrequently when first isolated it will not grow aerobically. After being cultivated for a short time, however, it grows freely under aerobic conditions, It is not constant in its sugar reactions. In the great majority cases it ferments glucose, lactose, saccharose, and salicin, raffinose, mannite, or inulin, A few strains, however but not 12 (about per cent.), ferment mannite. These mannite-
of
strains are identical morphologically with the non-mannite fermenters, and it has been shown by Douglas, Colebrook, and Fleming, in a report to the Medical Research Committee not yet published, by means of agglutination and absorption tests that serologically they are also identical. Clotting of milk.-This test is very inconstant, and we bave found that as regards the clotting of milk with these streptococci very much depends on the size of the tube in which the test is carried out. If the tube is of large size then the clotting is always delayed and it may even not take place in ten days, whereas in a small test-tube there is definite clotting in 24 hours. In a series of tubes of different sizes containing milk which had been heavily implanted with Strepto6oeo?ts pyogenes and incubated for five days it was observed that no clotting had occurred in the two largest tubes, in the third tube clotting had occurred but there was no contraction of the clot, while in the smallest tube there was firm clotting with much contraction of the clot. This clotting of the milk in the smallest tube had occurred in the first 24 hours. Even in small tubes, however, the clotting of milk by Streptococcus pyogents is quite inconstant and is worthless as a
fermenting
test.
the strains of this streptococcus power, but there seemed to be enormous differences in the amount of h2emolysin produced under the same conditions by streptococci which were isolated from the blood of septicasmic patients. In a number of cases the hsemolytio power was tested by centrifuging a broth culture and incubating for two hours at 370 C. dilutions of the clear supernatant fluid with washed human red corpuscles. In most cases, however, the question of whether these streptococci were hsemolytio or not was tested ty noting the appearance produced by their growth on a blood agar plate (see Fig. 2). InoidenOB of this stre ptococcus.-In a series of over 100 septic wounds (fractured femurs) which had remained at a base hospital for over seven days this streptococcus was present in almost every one. In cases of a similar nature where streptococci were recovered from the blood (47 cases) the organism was invariably of this type B 2
Haemolytio pomer.-All some hasmolytic
showed
50 ls the "Haemolytio" Charaoter of the Streptoaooeus of the characteristic colour of the discharges. Other organisms which spread around a wa’’d in the same way are B. proteus Fundamental Importance-i.e., Can Non-haemol.’ltio Streptoand diphtheroid bacilli. Now, as the 8treptooooous pyogenes ooooi be Ignored for Praatioal Purposes in Wozcnds?? As has been stated above, the only streptococcus which will grow in the discharges very much more readily than will these other organisms, it would be a miracle if it were we have found to give rise to serious complications in a spread in the same way. It is unfortunate that infection wound is the "pyogenes"type, which. belongs to the does not produce any characteristic change by streptococcus to of and we were forced haemolytic group streptococci, the smell or colour of the discharges, as it does not consider the non-haemoiytic streptococci to be of only obtrude itself on the notice of the surgeon until some secondary importance. In the more recent wounds, and serious complication arises. in had which gas gangrene especially in the wounds developed, there is to be found very freqaently streptococci Have any Points Bearing on the Methods of Recovery from of the I I fmcalis " type. These are not present with anything Streptococcus InfeJtions Come to Light, and, if so, like the same frequency in the latter cases. One of us Can these be Exploited in Treatment ? (A..F.) in conjunction with Douglas and Colebrookshowed In cases of septicaemia following serious wounds the prothat streptococci (and other organisms) had a powerful effect of recoveries is very small. Out of a series of in increasing the growth of anaerobic bacilli when grown portion 40 cases of septicæmia following compound fracture of the in tt be that these with them may streptococci femur we hive seen symbiosis. only four recoveries. The reason for of the " faecalis " type have some importance in the wound these recoveries is not very evident. All the patients who on account of this symbiotic action, but alone they do not recovered were treated with streptococcus vaccine, but it was seem to be of any importance in wounds at the base. very difficult to demonstrate in any of these septicaemia cases 3 What is the ’SCM7’(M of the Streptoooooi F01fY/d in W011,nds? ? any direct benefit from the vaccine. Examinations at a C.C.S. on recently inflicted wounds In some cases of pyaemia, however, and in many less severe have shown that in only about 15 per cent. of cases is cases, the administration of streptococcus vaccine in doses pyogenes present. Examinations at the base inof 1,000,000 to 5,000,000 was repeatedly followed by a drop Streptneoceus in tne temperature ana a cases which have been in more than a week reveal feeling of well-being to the the presence of this organpatient. It has often been demonstrated that, followism in over 90 per cent. of the wounds. ing the injection of streptococcus vaccine, there is a During the summer of 1918 we rise in the amount of antiexamined a bodies in the blood. In number of the gauze packs removed from wounds on cases of severe injury, such arrival at the base. When as a fractured femur, there the patient had been kept are very often portions of at the C. C. S. for more than the wound which are inthree or four days Streptoefficiently drained and to eoccus pyogenes was present which the blood fluids do in almost every case. These not have access, and this cases correspond, therefore, militates against any very dramatic effect following closely with the patients who have been in base hosthe administration of vaccine in such cases. We pitals for more than a few hold a very strong opinion, days. Where, however, the however, that in all septic patient had been sent wounds where the surgeon straight on to the base after excision of the wound we secures good drainage no found that Streptooooous harm would be done and much good woald result pyogenes was present only in 15 out of 75;cases. Although from a routine administrain the majority of the packs tion of stock streptococcus from these recent cases we vaccine in doses of from failed to find Streptococcus 1,000,000 to 5,000,000 once a week. It is not practicable pyogenes, we were able to recover other microbes in to make autogenous vacPl%te culture of 1 c.cm. of blood from a septieasmio patient taken immecines in every case, and it every case from those porafter disturbed washed. Note the diately being by being large number tions of the packs which has been demonstrated by of streptococcus colonies and the zone of haemolysis around each. came from the depths Douglas, Colebrook, and of the wound, and often these microbes were present in very Fleming that when an animal is with one strain of large numbers. The microbes isolated in these cases were Streptococcus pyogenes it develops antibodies (agglutinins) to the same degree to all strains. It would appear, therefore, chiefly anaerobic and aerobic bacilli and staphylococci. It has been conclusively demonstrated that Streptoooe01J.S that a stock vaccine would be as useful as an autogenous one. In cases of septicæmia it seems much more likely that pyogenes will grow much better than these other microbes in the blood fluids2 such as would be found in a recently streptococci are being continually thrown into the blood excised wound, so that had the streptococcus been present as stream from some septic focus than that they should actually a primary infection it should have been demonstrable on be growing and multiplying in the blood stream. If they arrival at the base. It is to be noted, therefore, that on did nourish in the circulating blood, then they should be arrival at the C. C. S. 15 per cent. of the men were infected present in much larger number than they are. If Ic.cm. of with 8streptococcus pyogenes,. on arrival at the base (when blood is taken from a septicasmic patient, mixed with liquid the cases had been sent straight on after operation) 20 per agar at 470 C., and plated, it is uncommon to get more than cent, were infected, but after a stay at the base of a week 100 colonies. Usually only two or three develop. This method has been found to be the best for blood over 90 per cent. were found to have Streptococcus pyogenes In quite a large series, of blood in their wounds. It would seem a warrantable deduction culture in such cases. from these observations that the streptococcal infection of cultures it has never failed to reveal streptococci when they wounds is in most cases a hospital infection, and it is were found in fluid cultures, and in two cases streptococci probable that in the dressing of the wound the infection is were found when they failed to develop from blood added to carried from one patient to another. remembered, however, that in a large series of puerIt has long been known that B. pyocyane2as is spread from 3 It should be cases in which streptococci were demonstrated in the peral septicaemia one patient to another in a ward by faulty technique in I blood Western (THE LANCET, 1912, i., 351) by the use of vaccines obtained a as this infection is manifest to naked the very high percentage of recoveries (45 as against about 10 dressing, in a control series not treated by vaccines). These puerperal septi1 THE cæmias do not seem to be very different from septicaemia following a LANCET, 1917, i., 604. 2 Wright: Proceedings of the Royal Society of Medicine, 1915. septic wound.
not
I in
injected
I
eye byB
DR. H. J. B. FRY : CERTAIN ORGANISMS ISOLATED FROM INFLUENZA CASES.
[
51
broth or glucose broth. It has also the great merit that the NOTE ON number of streptococci in the circulating blood can be CERTAIN ORGANISMS ISOLATED FROM determined. The technique is as follows :is case blood from the 1 c.cm. of CASES OF INFLUENZA. suspected septicaemio added to about 5 c.cm. of water. The blood will thus be BY H. J. B. FRY, M.D. OXON., laked and the clotting power diminished, so that it can readily be carried back to the laboratory before coagulation CAPTAIN, R.A.M.C. (T.). takes place- It is then mixed with about 20 c.cm. of agar at 47° C., poured into a Petri dish, allowed to set, and incubated. IN the course of investigation of material derived from In 24 hours the colonies can easily be seen. Minced meat medium, such as is commonly used in the cases of influenza during the three waves of the present cultivation of anaerobes, furnishes a better fluid medium for when searching for Pfeiffer’s bacillus, Gramblood culture in these surgical cases than does broth, glucose epidemic, "Pfeiffer-like" bacilli were frequently isolated. negative, broth, or citrated broth. In several cases we have obtained not, however, hasmophilic, and grew rapidly and growths of streptococcus from the blood in this medium They were They have been isolated from when they failed to develop in the broth cultures. It has readily on ordinary agar. the advantage that anaerobes, if present, will also develop. sputum, post-mortem material, and in blood culture. The The figure represents a plate made from 1 c.cm. of blood organisms derived from the latter source deserve further from a patient with septicaemia following a flesh wound in description. the thigh. It shows very many more streptococci than are I They were isolated from the blood of two German prisoners, out of four cases examined, at the commencement of the in the Two after blood. the usually present days specimen third wave of the epidemic in February, 1919. The camp was taken the patient died, and the autopsy showed, in addition to a septic thigh wound, abscesses in the hand, ’, to which the prisoners had belonged had escaped the two wrist, both elbows, neck, and a very large abscess in the previous waves, but was overwhelmed by the present one, a buttock. The specimen of blood was taken immediately the large proportion of the prisoners being severely attacked. The organism was obtained in 2 per cent. glucose broth, orderlies had finished washing the patient, during which and he must of have been disappeared in 24 hours in the blood culture, as round or necessity process considerably turbed, and it seems probable that the large number of oval Gram-negative " yeast-like " bodies, 3-5,u long by 2-4µ streptococci in the blood was due rather to this disturbance broad. Subculture to agar produced, not the above organisms but Gram-negative bacilli, varying in size from coccal or than to their growth in the blood stream. It is unlikely, also, that the small number of streptococci cocco-b3cillary forms to short filaments. The "yeast-like" present in the blood stream in the ordinary case of septi- bodies rapidly disappeared from the blood culture, and were caemia would be able to flourish in that situation, as the serum replaced by clumps of Gram-negative bacilli, in the neighof these patients show by Sir Almroth Wright’s sero-culture bourhood of which could be seen, in some cases, Grammethod a very much enhanced bactericidal power to Strepto- negative amorphous masses, resembling the ruptured envelopes " coccus pyogenes.4 (The bactericidal power of normal serum of the above-mentioned yeast-like" bodies. to this microbe is practically nil.) Chccraeters of Organism : Pathogenesis. So far as we know, streptococci are destroyed in the body The bacilli were pure in subculture, and had the by three agencies: (1) bactericidal power of the serum ; and cultural characters :(2) direct bactericidal power of the leucocytes (without morphological and cultural elearccoters.-Small non-sporing Morphology phagocytosis) ; (3) phagocytosis due to the combined action bacilli, often grouped in parallel, or as diplo-bacilli, 1-21-’ in of the serum (opsonic power) and leucocytes. In streptobut varying in size from coccal forms to short filacoccal septicaemia these are changed from the normal as length, ments. The smaller forms are actively, but the larger forms follows. are motile. They are Gram-negative but not acid1. Bactericidal power of the sercum. (This, as stated above. fast.feebly, Polar staining is not usually present. They are aerobic and grow rapidly and well on agar, forming a whitish-grey 2. Direct bactericidal power of the leucocytes.--It has been moist growth of circular, slightly flattened colonies, about shown5 that living leucocytes have the power of destroying 0’5 mm. in diameter. Viewed by transmitted light, the streptococci without ingesting them. This power of the colonies are translucent and slightly iridescent. In stableucocytes is apparently unaltered in septicaemia cases culture on gelatin there is a white growth, confined to the except that as there is always a leucocytosis in these cases needle track, without extension on the surface, and the the power is more manifest. is not liquefied. Broth is rendered turbid, with a 3. Phagoaytosis.-In some cases of septicæmia the serum gelatin whitish, stringy deposit. flocculent, has lost completely or almost completely its opsonic power The fermentation reactions are as follows: Acid pro(and also its complementing power). The phagocytic power duction but no gas in dextrose, maltose, and mannite. No of the leucocytes is not diminished. change in lactose, cane-sugar, salicin, or inulin. Litmus It would appear from these observations that, as a rule, it milk is first rendered faintly acid and then becomes strongly is not the circulating blood which is at fault in cases of without any clotting. Neutral-red broth is rendered alkaline, we have to alkaline. streptococcal septicaemia, and in all probability There is a fairly well-marked indol reaction after look for some deficiency in the local protective mechanism 48 hours’ growth in peptone water. Stalactite growth was which allows access of the streptococci to the blood stream. not obtained in butter-fat broth. It would seem to follow, also, that for the successful treatcent. salt agar, numerous yeast-like forms Grown on 6 ment of a case of septicaemia the most essential element were obtainedper those obtained in the blood resembling would be the thorough local treatment of the infected focus. with filamentous, curved, and swollen culture, together It has been observed that when an infection has become forms. The organism resists heating to 65° C. for 30 minutes, circumscribed by the collection of leucocytes in the walls but is killed at a temperature of 600 C. for 1 hour. of the wound and by the other factors which operate was highly pathogenic to the Pathogenesis.-The locally in this connexion, it is very difficult to graft a rat and guinea-pig. organism 0’25 c.cm. of a saline emulsion of a serious streptococcal infection on the wound. It follows 24-hour culture by intrathoracic injection killed a white from this that the utmost care should be taken in the first rat in 17agar hours. The lesions produced were ecchymoses and few days after the injury to keep out the streptococcus extravasations on the surfaces of both lungs, and to avoid any treatment which will inhibit the defensive hæmorrhagic The heart was which were congested and oedematous. processes developing. In the after-treatment fresh tissue engorged and filled with clot. The organism was recovered should only be opened up when there is a very urgent in pure culture from heart, lungs, and spleen. necessity. A similar dose by intrathoracic injection killed a guineaIn conclusion, we wish to express our thanks to Major M. in five days, causing a slight caseous nodule at the site Sinclair and our other surgical colleagues for permitting us pig of inoculation, sero-purulent effusions into both pleural sacs, to make observations on patients under their care ; to ar.d lobular pneumonia with haemorrhages in both lungs. Captain L. Colebrook for permission to use some of his The bronchial glands were greatly enlarged and showed experimental work ; and to the Medical Research Committee caseous nodules. The heart was dilated and filled with for supplying us with apparatus which made the work easier. clot. The organism was recovered in pure culture from the effasion, lungs, heart blood, tracheal mucus, and 4 For this observation we are indebted to pleural Captain L. Colebrook. spleen. By intraperitoneal inoculation death was caused 5 Wright, Fleming, and Colebrook, THE LANCET, 1918, i., 831.
following
is
increased.)
.