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Pneumonia and the pneumococci
274
TUBERCLE
TUBERCLE. MARCH, 193:l. Pneumonia and the Pneumococci. The intensive bacteriological researches that have been carried out within recent years in respect of the mtiology of the pneumonias has greatly simplified the work of clinicians in the prophylaxis, diagnosis, prognosis and treatment of the disease in its varying manifestations. Three now studies which have recently been published [1, 2, 3] have carried our knowledge a step further; and have cleared up several points on which precise information has been lacking. D r . W. G. Smillie in his paper on " T h e Epidemiology of Lobar Pneum o n i a " has studied the prevalence of specific strains of pneumococci in the nasopharynx of 582 immediate family contacts of actual cases of lobar pneumonia and also in 493 controls. Among over a thousand persons tbus studied, Types I and I I pneumococci were found to be much more prevalent in the nasopharynx in immediate family contacts of cases of lobar pneumonia due to the homologous type than in the population at large ; while, on the other hand, the higher types of pneumococci,III to X I X inclusive, were just as prevalent in the throat in the general population as in the f,~mily contacts of eases of pneumonia due to these specific types. The whole group of pneumococei was less prevalent in the late summer months than in the winter and early spring. Dr. Smillie's studies further suggest that epidemics of family colds have some relationship to the prevalence of homologous types of pneumococci in contacts of lobar pneumonia duo to Types I and I I . Drs. t2. Heffron and G. W. Anderson, describing a two years' study, still incomplete, of lobar pneumonia in Massachusetts, confine themselves to the clinical aspect of problems in connection with the serum treatment of Type I pneumonia. The serum experimented with was L. D. :Felton's [4] concentrated Type I and I I antibody solution,
[ M a r c h , 1934
employed by 63 eollabora.ting physicians in the treatment of 421 cases of pneumonia. I t was advised that the serum treatment should be begun as soon as the clinical diagnosis could be made, but in no case was it to be instituted after the fourth day of the disease. Sensitivity to serum as detected by the ophthalmic test was determined in every ease, a positive test or a history of asthma, hay fever, eczema, urticaria or angioneurotic oedema b e i n g considered a contra-indication to serum therapy. The serum, given intravenously, was administered iu doses of 5, 25 and 45 c.e. at intervals of two hours. If a Type I or I I pneumococcus was found, further serum might be given according to clinical indications. Among the 421 serum.treated cases, which included all four groups of pneumococcus and 36 cases of strepto. coceic and miscellaneous infections, the fatality rate was 18"7 per cent., as compared with a fatality rate in 349 untreated cases of 20'3 per cent. The results of serum therapy in 188 Type I cases of lobar pneumonia were very striking, giving a case fatality rate of 10'6, as compared with a rate of 25"9 per cent of 85 untreated Cases of the same type. :Even in treated patients with a positive blood cultu.re the case fatality rate was only 11"4: per cent. The results of this study are therefore extremely encouraging, suggesting that a greater utilisation of Felton's concentrated antibody solution may greatly reduce the present high pneumonia death-rate. In the third paper Drs. W. D. Sutliff and M. Finland discuss the significance of the newly classified t y p e s - - T y p e s I V to X X - - o f pneumococei in disease. Certain individual characteristics of the pneumonias caused by these new types. of which the most frequent are V, V I I and V I I I , are described and compared witl, the better known types I, I I and I I I . Type u forms 5 per cent. of the total of pneumococcic pneumonias or empyemas, causing either pneumonia or empyema in 96 per cent. of the cases in which it is found, and leading to purulent complications in 28 per cent. of the pneumonia cases. Type V is associated with lobar pneumonia rather
March, 1934]
PNEUMONIA AND
than.bronchopneumonia in 81 percent. of tile cases, its age distribution being quite irregular. Type V I I is associated with pneumonia or empyema in 80 per cent. of the cases, but leads to purulent c6mplications in 11 per cent. Type V I I I is associated with pneumonia or empyema in 90 per cent. of the cases in which it is isolated, and though it has the low mortality of 23"8 in lobar pneumonia, yet owing to an average bronchopneumonia mortality of 67 per cent., it has a total mortality of 38 per cent.
THE
PNEUMOCOCCI
9~75
The writers of this valuable paper conclude that the experience afforded by the bacteriological classification of this series of pneumonia cases indicates that " t h e pneumonias due to different serologic strains of pueumococci and due to other organisms m a y be regarded as separate entities." REFERENCES. [1] [2] [3] [4]
Journ. Amer. Med. Assoc., 1933, 1Ol, 1281 Ibid., 1286. lbid., 12S9. Boston Med. and Svrg. Jou~n., 19'24, it0
819.
BOOK N O T I C E S A N D A B S T R A C T S . Bo~k Notices. Report of an I n v e s t i g a t i o n into the Causes of the Continued. High Death R a t e from Tuberculosis in Certain P a r t s of North Wales. :By Dr. Herbert D. Chalke. King Edward VII[ Welsh National 3Iemorial Association, Memorial Office-%Cardiff. 193"3. I t is probably by now a matter of common knowledge that a scheme for the detailed investigation into the abnornrally high tuberculosis death rate in certain parts of North Wales was set on foot, and has now been carried to a successful conclusion. This report by Dr. Herbert Chalke, who undertook the survey, is one of great interest, space, however, forbidding more than a brief review of his main findings. Infection was found to take place largely in the home, facilitated by intimate contact between closely related families in the districts surveyed, heavy rainfall, little outdoor recreation, and frequent meetings in crowded, poorly ventilated chapels and halls. :Resistance to infection was found to be lowered by many factors, including malnutrition, fatigue, injury, occupational risks, defective housing and sanitation. Of all these Dr. Ghalke considers that defective diet is of overwhelming importance in lowering bodily resistance, the deficiency in the districts investigated being mainly in regard to milk, fresh meat, fruit and ~;egetables. With regard to preventive measures, much could be done by intensive hy-
gienie education and by " drilling the patient and the family in the measures necessary to prevent the dissemination and more particularly the direct transmission of tubercle bacilli." Such measures would include the regular disinfection of the homes of open cases of tuberculosis during life ; the examination of the sputum of all persons, especially quarry men, with chronic coughs ; and increased attention to dustprevention measures in slate quarries. Other recommendations include an extensive campaign towards ensuring pure milk supply, the replacing of damp cottages by modern houses on dry sites ; particular stress also being laid on the the necessity for a reform in the dietetic habits of the people, aided by the issue by the association of a well-planned dietary which would be within the means of the poorer classes. These and m a n y other measures recommended would, it is confidently expected, bring about a gradual but definite decline in tuberculosis mortality in Wales. Tile survey has been well planned and adequately carried out, amply repaying the expense and vast amount of labour ~hat must have been expended upon it. Du Pneumothorax b, la Phrduicez. tomie. :By Dr. Jean Morin. 1933. Paris: .SIasson ct Cic. Pp. 35. Price 20 fr. The material on which this study is based consists of some 495 dossiers, including every case of artificial
TUBERCLE
TUBERCLE. MARCH, 193:l. Pneumonia and the Pneumococci. The intensive bacteriological researches that have been carried out within recent years in respect of the mtiology of the pneumonias has greatly simplified the work of clinicians in the prophylaxis, diagnosis, prognosis and treatment of the disease in its varying manifestations. Three now studies which have recently been published [1, 2, 3] have carried our knowledge a step further; and have cleared up several points on which precise information has been lacking. D r . W. G. Smillie in his paper on " T h e Epidemiology of Lobar Pneum o n i a " has studied the prevalence of specific strains of pneumococci in the nasopharynx of 582 immediate family contacts of actual cases of lobar pneumonia and also in 493 controls. Among over a thousand persons tbus studied, Types I and I I pneumococci were found to be much more prevalent in the nasopharynx in immediate family contacts of cases of lobar pneumonia due to the homologous type than in the population at large ; while, on the other hand, the higher types of pneumococci,III to X I X inclusive, were just as prevalent in the throat in the general population as in the f,~mily contacts of eases of pneumonia due to these specific types. The whole group of pneumococei was less prevalent in the late summer months than in the winter and early spring. Dr. Smillie's studies further suggest that epidemics of family colds have some relationship to the prevalence of homologous types of pneumococci in contacts of lobar pneumonia duo to Types I and I I . Drs. t2. Heffron and G. W. Anderson, describing a two years' study, still incomplete, of lobar pneumonia in Massachusetts, confine themselves to the clinical aspect of problems in connection with the serum treatment of Type I pneumonia. The serum experimented with was L. D. :Felton's [4] concentrated Type I and I I antibody solution,
[ M a r c h , 1934
employed by 63 eollabora.ting physicians in the treatment of 421 cases of pneumonia. I t was advised that the serum treatment should be begun as soon as the clinical diagnosis could be made, but in no case was it to be instituted after the fourth day of the disease. Sensitivity to serum as detected by the ophthalmic test was determined in every ease, a positive test or a history of asthma, hay fever, eczema, urticaria or angioneurotic oedema b e i n g considered a contra-indication to serum therapy. The serum, given intravenously, was administered iu doses of 5, 25 and 45 c.e. at intervals of two hours. If a Type I or I I pneumococcus was found, further serum might be given according to clinical indications. Among the 421 serum.treated cases, which included all four groups of pneumococcus and 36 cases of strepto. coceic and miscellaneous infections, the fatality rate was 18"7 per cent., as compared with a fatality rate in 349 untreated cases of 20'3 per cent. The results of serum therapy in 188 Type I cases of lobar pneumonia were very striking, giving a case fatality rate of 10'6, as compared with a rate of 25"9 per cent of 85 untreated Cases of the same type. :Even in treated patients with a positive blood cultu.re the case fatality rate was only 11"4: per cent. The results of this study are therefore extremely encouraging, suggesting that a greater utilisation of Felton's concentrated antibody solution may greatly reduce the present high pneumonia death-rate. In the third paper Drs. W. D. Sutliff and M. Finland discuss the significance of the newly classified t y p e s - - T y p e s I V to X X - - o f pneumococei in disease. Certain individual characteristics of the pneumonias caused by these new types. of which the most frequent are V, V I I and V I I I , are described and compared witl, the better known types I, I I and I I I . Type u forms 5 per cent. of the total of pneumococcic pneumonias or empyemas, causing either pneumonia or empyema in 96 per cent. of the cases in which it is found, and leading to purulent complications in 28 per cent. of the pneumonia cases. Type V is associated with lobar pneumonia rather
March, 1934]
PNEUMONIA AND
than.bronchopneumonia in 81 percent. of tile cases, its age distribution being quite irregular. Type V I I is associated with pneumonia or empyema in 80 per cent. of the cases, but leads to purulent c6mplications in 11 per cent. Type V I I I is associated with pneumonia or empyema in 90 per cent. of the cases in which it is isolated, and though it has the low mortality of 23"8 in lobar pneumonia, yet owing to an average bronchopneumonia mortality of 67 per cent., it has a total mortality of 38 per cent.
THE
PNEUMOCOCCI
9~75
The writers of this valuable paper conclude that the experience afforded by the bacteriological classification of this series of pneumonia cases indicates that " t h e pneumonias due to different serologic strains of pueumococci and due to other organisms m a y be regarded as separate entities." REFERENCES. [1] [2] [3] [4]
Journ. Amer. Med. Assoc., 1933, 1Ol, 1281 Ibid., 1286. lbid., 12S9. Boston Med. and Svrg. Jou~n., 19'24, it0
819.
BOOK N O T I C E S A N D A B S T R A C T S . Bo~k Notices. Report of an I n v e s t i g a t i o n into the Causes of the Continued. High Death R a t e from Tuberculosis in Certain P a r t s of North Wales. :By Dr. Herbert D. Chalke. King Edward VII[ Welsh National 3Iemorial Association, Memorial Office-%Cardiff. 193"3. I t is probably by now a matter of common knowledge that a scheme for the detailed investigation into the abnornrally high tuberculosis death rate in certain parts of North Wales was set on foot, and has now been carried to a successful conclusion. This report by Dr. Herbert Chalke, who undertook the survey, is one of great interest, space, however, forbidding more than a brief review of his main findings. Infection was found to take place largely in the home, facilitated by intimate contact between closely related families in the districts surveyed, heavy rainfall, little outdoor recreation, and frequent meetings in crowded, poorly ventilated chapels and halls. :Resistance to infection was found to be lowered by many factors, including malnutrition, fatigue, injury, occupational risks, defective housing and sanitation. Of all these Dr. Ghalke considers that defective diet is of overwhelming importance in lowering bodily resistance, the deficiency in the districts investigated being mainly in regard to milk, fresh meat, fruit and ~;egetables. With regard to preventive measures, much could be done by intensive hy-
gienie education and by " drilling the patient and the family in the measures necessary to prevent the dissemination and more particularly the direct transmission of tubercle bacilli." Such measures would include the regular disinfection of the homes of open cases of tuberculosis during life ; the examination of the sputum of all persons, especially quarry men, with chronic coughs ; and increased attention to dustprevention measures in slate quarries. Other recommendations include an extensive campaign towards ensuring pure milk supply, the replacing of damp cottages by modern houses on dry sites ; particular stress also being laid on the the necessity for a reform in the dietetic habits of the people, aided by the issue by the association of a well-planned dietary which would be within the means of the poorer classes. These and m a n y other measures recommended would, it is confidently expected, bring about a gradual but definite decline in tuberculosis mortality in Wales. Tile survey has been well planned and adequately carried out, amply repaying the expense and vast amount of labour ~hat must have been expended upon it. Du Pneumothorax b, la Phrduicez. tomie. :By Dr. Jean Morin. 1933. Paris: .SIasson ct Cic. Pp. 35. Price 20 fr. The material on which this study is based consists of some 495 dossiers, including every case of artificial