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Prevention of hospital infection of wounds
PUBLIC HEALTH, May, 1945 infections arising in hospital have in t h e past t e n d e d to be d i s r e g a r d e d o r n o t recognised so l o n g as t h e y were m i l d a n d riot too widespread, a n d t a k e n seriously o n l y if t h e infections were severe or o n e o r m o r e deaths occurred. I n relation to hospital infection I w o u l d class the medical staff of hospitals, visiting a n d resident, into t h e ignorant, t h e d i e - h a r d unbelievers, t h e indifferent, a n d the actively interested. T h e i g n o r a n t are largely t h e recently qualified doctors, a n d t h e y are i g n o r a n t because t h e y h a v e n o t b e e n p r o p e r l y t a u g h t a n d h a v e to gain t h e i r k n o w l e d g e t h r o u g h experience a n d mistakes. T h i s class is decreasing b u t n o t quickly e n o u g h . A s residents in hospital, t h e y m u s t b e o n t h e look-out for t h e first signs of s p r e a d of infection, a n d m u s t initiate m e a s u r e s to control it. I t is o n t h e m a n d o n t h e n u r s i n g staff t h a t we m u s t largely d e p e n d to control infection, because t h e y are in almost c o n s t a n t contact w i t h t h e patient, whereas the visiting p h y s i c i a n or s u r g e o n sees each p a t i e n t for a s h o r t t i m e a n d m a n y t e n d to r e g a r d each p a t i e n t in a m u l t i p l e - b e d w a r d as a separate m o r b i d unit, a n d n o t as a m e m b e r of a small h e r d s u s c e p t i b l e to s p r e a d i n g infection. W e k n o w the disasters w h i c h m a y o c c u r if the p a t i e n t w i t h r h e u m a t i c f e v e r o r thyrotoxicosis or failing h e a r t gets a t h r o a t infection w i t h a h a e m o l y t i c streptococcus. T h e dieh a r d u n b e l i e v e r s , f o u n d m a i n l y a m o n g t h e o l d e r m e m b e r s of the staff w h o are u n r e c e p t i v e of n e w e r knowledge, have also decreased greatly. B u t t h e r e are still far too m a n y w h o are indifferent, a n d it is m o r e t h a n u n f o r t u n a t e if these b e c o m e teachers of m e d i c a l s t u d e n t s . T h e actively i n t e r e s t e d are increasing rapidly in n u m b e r , a n d it is to be h o p e d t h a t t h e i r i n t e r e s t will be sustained, b e c a u s e t h e y will have to fight against ignorance, apathy, a n d o b s t r u c t i o n . M.R.C. W a r M e m o . No. 11 (1944) o n T h e C o n t r o l o f C r o s s - I n f e c t i o n in H o s p i t a l s has b e e n t a k e n very seriously b y m a n y hospitals, m o s t l y t e a c h i n g hospitals, w h e r e c o m m i t t e e s have b e e n f o r m e d to c o n s i d e r t h e whole q u e s t i o n a n d act o n t h e r e c o m m e n d a tions p u t forward, especially as regards ventilation, b e d - s p a c i n g , isolation a c c o m m o d a t i o n , a d e q u a t e sterilisation a n d disinfection e q u i p m e n t a n d t e c h n i q u e , a n d sufficient t r a i n e d staff to maintain a high-grade nursing technique. H o s p i t a l s in w h i c h little or n o action is t a k e n to p r e v e n t or c o n t r o l infection m a y b e said to have a l m o s t a vested i n t e r e s t in disease. I w o u l d like to see the success of work in a h o s p i t a l j u d g e d , n o t o n l y b y statistics s h o w i n g a m o n g o t h e r t h i n g s the increasing n u m b e r of cases a d m i t t e d for m e d i c a l or surgical t r e a t m e n t d u r i n g e a c h year, b u t also b y figures s h o w i n g decreases f r o m year to year in t h e n u m b e r of b e d - d a y s p e r patient, in t h e n u m b e r of cases of i n f e c t i o n arising in hospital, a n d in t h e n u m b e r of cases t r a n s f e r r e d to isolation hospital.
Inoculation Infection I n o c u l a t i o n infection affects n o t o n l y school i m m u n i s a t i o n clinics, b u t also hospital w a r d s a n d o u t - p a t i e n t clinics. A n u m b e r of o u t b r e a k s of infection w i t h h a e m o l y t i c streptococci, S t a p h . aureus a n d even t u b e r c l e bacilli, at t h e i n o c u l a t i o n site after injection w i t h d i p h t h e r i a p r o p h y l a c t i c A . P . T . , have c o m e to o u r notice d u r i n g t h e last t h r e e years. T h e r e is u r g e n t n e e d for a radical o v e r h a u l of t h e t e c h n i q u e of sterilisarion, use, a n d care of syringes, a n d the t e a c h i n g of careful a n d foolp r o o f m e t h o d s to m e d i c a l s t u d e n t s a n d n u r s i n g staff. I t is strange how, w h e n q series of severe reactions, s o m e t i m e s a c c o m p a n i e d b y abscess formation, occurs in a d i p h t h e r i a i m m u n i s a t i o n clinic o n a particular occasion t h e cause of the reaction is n e a r l y always a t t r i b u t e d to t h e A . P . T . , w h e n p r o b a b l y the i n o c u l a t i o n t e c h n i q u e is at fault. That the sterilisation, care, a n d use of t h e l u m b a r p u n c t u r e n e e d l e a n d of syringes u s e d for spinal analgesia also n e e d a t t e n t i o n has b e e n s h o w n b y S m i t h a n d S m i t h (1941), w h o r e p o r t e d a hospital o u t b r e a k of m e n i n g i t i s caused b y infection f r o m " sterile " w a t e r in w h i c h needles a n d syringe were placed. E v a n s (1945) has also r e c o r d e d two fatal cases of Ps. p y o c y a n e a m e n i n g i t i s after spinal anaesthesia in h o s p i t a l ; a n d C a i r n s (1945) has b e e n i m p r e s s e d b y t h e n u m b e r of cases of m e n ingitis after l u m b a r p u n c t u r e . A n o t h e r d i s t u r b i n g indication of t h e failure of c u r r e n t syringe t e c h n i q u e is the a c c u m u l a t i n g evidence t h a t t h e s e are n o t t h e only inoculations w h i c h h a v e b e e n followed b y u n t o w a r d results. T h e association of h e p a t i n s a n d j a u n d m e w t t h t h e a d m m ~ s t r a t m n of insulin ( G r a h a m ,
by 1938), t h e gold t r e a t m e n t of a r t h r i t i s (Hartfall, G a r l a n d , a n d Gotdie, 1937 ; Hartfall, 1944), a n d t h e t r e a t m e n t of syphilis w i t h organic arsenicals ( M a c C a l l u m , 1 9 4 3 ; S a l a m a n , K i n g , Williams, a n d Nicol, 1944 ; S h e e h a n , t944) indicate t h a t t h e increasingly w i d e s p r e a d use of biologicals a n d d r u g s a d m i n i s t e r e d b y syringe accentuates the risks o f infection. F u l l precautions s h o u l d be t a k e n b y the a d o p t i o n of a careful a n d rigid t e c h n i q u e of syringe sterilisation.
Conclusion I n conclusion, I r e c o m m e n d t h e practice of t h e p r o c e d u r e s p r o p o s e d in M . R . C . W a r M e m o s . No. 6 (1941) o n T h e P r e vention o f H o s p i t a l I n f e c t i o n o f Wounds,. a n d No. 11 (1944) o n T h e C o n t r o l o f C r o s s - I n f e c t i o n in H o s p i t a l s . I have o m i t t e d to lay a n y stress on t h e p a r t p l a y e d b y t h e bacteriologist in t h e p r e v e n t i o n a n d control of h o s p i t a l infection, b e c a u s e his r61e is ancillary to a d m i n i s t r a t i v e p r o c e d u r e s a n d to t h e ritual o f t e c h n i q u e a n d n u r s i n g practice. B u t I feel t h a t m o r e use s h o u l d be i n a d e of his k n o w l e d g e a n d experience t h a n has h i t h e r t o b e e n t h e case. H e can b e as o b s e r v a n t a n d critical as t h e s u r g e o n in t h e detection o f flaws i n aseptic t e c h n i q u e , a n d in a d v i s i n g o n p r o c e d u r e s w h i c h p e r h a p s c o m e tess t h a n they s h o u l d w i t h i n t h e direct p u r v i e w o f the p h y s i c i a n a n d surgeon. I lay stress o n t h e i m p o r t a n c e of b e t t e r e d u c a t i o n of the n u r s e a n d medical s t u d e n t in t h e principles a n d practice of p r e v e n t i v e m e a s u r e s in t h e i r a p p l i c a t i o n to hospital practice. P~EFERENCES Aerobiology. (1942). Washington D.C. American Association for the Advance-
ment of Science. ALLISON, V. D. (1942). Control of the Common Fevers. p. 57, Lancet, 1942. American Hospital Association, Chicago, Illinois. (1940).~ Bulletin No. 203. Ultra-violet Rays as a Sterilisation Agent in Hospitals. ANDR~'ES, C.H. (1940). Lancet, 2, 770. BOURDILLON,R. B., LIDWELL,O. M., and LOVELOCK,J E. (1942). Brit. med, ft., 1, 42. BUCHBINDER,L. (1942). Aeroblology. Washington, D.C. American Association for Advaneeanentof Science. p. 267. BULLOUGtt,W.A. (1942). Proc. roy. Soc. Med., 35, 371. CAIE2~S,H. (1945). Brit. reed. ft., 1, 379. ELCOCK, C.E. (1942). Proc. roy. Soc. Med., 3S, 359. EVANS, F. T. (1945). Lancet, 1, 115. GARROD,L.P. (1944). Brit. meal. ft., 1, 245. GI~HAM, G. (1938). Lancet, 2, 1. HARTFALL,S.J. (1944). Ibid., 2, 358. --, GARLAND, H. G., and GOLD1E, W. (1937). lbld., 2, 838. HOLLAENDER,A. (1943). Amer. J. publ. Hlth., 33, 980. LOVELOCK,J. E., L~iDWELL,O. M., and RAYMOND,W. F. (/944). Nature, 153, 20. MACCALLUM,F.O. (1943). Brit. g, verier. Dis., 19, 63. MCCLtmE, W.B. (1944). Canad. ft. publ. Hlth., 35, 380. M.R.C. (1941). The Prevention of Hospital Infection of Wounds. War Memo. No. 6. ~.~t(1944)" The Control of Cross-infection in Hospital Wards. War Memo. No. MITMAN, M. (1945). Brit. reed. J., 1, 71. ROBERT$ON,O. H., BIGO, E., PUCK, T. T., and MILLER, B. F. (1942)..~. exp. Med., ~S, 593. •, HAMBURGER,M., LOOSLI, C. G., PUCK,T. T., LEMON,H. M., and WIs~, H. (1944)..% Amer. reed. Ass., 126, 993. SALAMAN,M. S., KING, A. J., WILLIAMS,D. I., and NICOL, C.S. (1944). Lancet, Z, 7. SHEEHAN,H.L. (1944). ].bid., 2, 8. SMITH, W., and SMITH, M. M. (1941). Ibid., 2, 783. VANDEN ENDE, M., and THOMAS,J.C. (1941). Ibid., 2, 755. WE~t.LS,~V. F., WELLS,M. W., and WILDER,T.S. (1942). Amer. ff. Hyg., 3~, 07. WRIGHT, J., CRUICKSHANK,R., and GUNN, V¢. (1944). Brit. med. ft., 1, 611.
PREVENTION
OF
HOSPITAL WOUNDS
INFECTION
OF
B y J. GOUGH, M.D., L e c t u r e r in P a t h o l o g y , W e l s h N a t i o n a l S c h o o l o f M e d i c i n e
I n t h e early m o n t h s of t h e w a r t h e m e m b e r s o f t h e p a t h o l o g y staff of t h e W e l s h N a t i o n a l School of M e d i c i n e t r i e d to increase t h e i n t e r e s t of h o s p i t a l authorities in t h e p r o b l e m of hospital infection. T h e h o s p i t a l medical a u t h o r i ties w h o were a p p r o a c h e d agreed to p u t into o p e r a t i o n as far as possible t h e r e c o m m e n d a t i o n s w h i c h are i n c l u d e d in t h e M.R.C. publication The Prevention of Hospital Infection of W o u n d s w h i c h a p p e a r e d in 1941. A f t e r four years we are i n a p o s i t i o n to j u d g e h o w m a n y of t h e s e r e c o m m e n d a t i o n s were actually p u t into effect, or, in s o m e instances, h o w few. B u t w e c a n n o t say t h a t we are i n a p o s i t i o n to j u d g e w h a t benefits, if a n y , have occurred. T h e m a i n rules c o n c e r n e d a t e a m m e t h o d for surgical dressing, n o n - t o u c h f t e c h n i q u e , efficient m a s k i n g , the oiling of floors, a n d efficient m e t h o d s for t h e sterilisation of i n s t r u m e n t s . These were directed
90 particularly to prevent streptococcal infection. S u c h infection was expected in war wounds if the experience of the last war was to be repeated. We have seen, however, extremely little streptococcal infection. S o m e cases returning from N o r t h Africa in 1942-43 showed it, b u t practically none of the w o u n d e d f r o m E u r o p e since the s u m m e r of 1944 have had this infection. W e cannot say w h e t h e r the absence of streptococcal infection is due to the better surgical technique in hospitals, or to the better t e c h n i q u e in the field, or to chemot h e r a p y - f o r there has been a liberal and almost universal use of sulphonamides or p e n i c i l l i n - - o r to all together. A l t h g u g h streptococcal infections have been few and staphylococcal infections also comparatively rare, infections with gramnegative bacilli have been quite c o m m o n and have often been acquired in h o s p i t a l ; and it is mainly abbut such infections that I wish to speak. At the present t i m e the incidence of such infections appears to be a better criterion of hospital infection. Hospital Infection with Gram-negatlve Bacilli I came into contact w i t h this f o r m of hospital infection w h e n working with Dr. Dillwyn T h o m a s at Sully. H e had been draining tuberculous cavities by m e a n s of a catheter inserted t h r o u g h the chest wall (Monaldi technique). T u b e r culous cavities in their natural state are never secondarily infected, but after drainage they usually become so. W e m e t a variety of organisms, but most c o m m o n l y Ps. pyocyanea. I n o r d e r to try out chemical substances w h i c h could control this infection, I looked for pyocyanens infections in other hospitals, especially in surface wounds and ulcers w h i c h would be accessible to treatment and where results could be judged. I n the several hospitals where I looked for pyocyaneus infection, there was ample material. T h e s e included general hospitals, and hospitals w h e r e military patients w i t h recent and old wounds were being treated. It was obvious that m a n y cases of burns and m a n y surface wounds with skin loss, including c o m p o u n d fractures, became infected with gram-negative organisms and especially pyocyaneus while in general hospitals. S o m e had o t h e r infections as well. Investigations were carried out to see how far it would be possible to prevent infection in burns as Colebrook and others had done. Bnrils
I started by treating the burns in a casualty department. Operating theatre conditions were used ; , no gloves were worn, but a strict n o n - t o u c h technique was employed. T h e dressings were changed as infrequently as possible, and in spite of the fact that these patients were treated at h o m e and ret u r n e d for dressings about every five days the incidence of infection in 70 cases was very low, and no pyocyaneus infection occurred in any of them. P o s s i b l ~ these results contrasted with those of patients in the wards because they were comparatively m i n o r burns, b u t in April, May, and June of 1944, w h e n hospital beds for civilians were scarce, we treated as out-patients m a n y w h o in normal times w o u l d have been admitted. Again, the incidence of infection was low and no pyocyaneus infection occurred. Since that t i m e m a n y in-patients have been treated likewise. W h e n the technique has been rigidly followed, and provided the dressings have been infrequent and carried out u n d e r theatre conditions, the results have on the whole been satisfactory. It has not been possible to p r e v e n t infection in deep burns w h e n sloughing of the whole skin thickness occurred, but there has been great i m p r o v e m e n t in the results in superficial ones. F o r m e r l y , w h e n dressings had been done in wards without rigid technique, and especially if they had been done frequently, infection became c o m m o n and the results indifferent or poor. Burns of a m i n o r degree which should have healed in ten days had been converted as a result of infection into granulating areas requiring weeks to heat, and often requiring skin-grafting. I f the rules for w o u n d dressings set out in the M . R . C . m e m o r a n d u m could have been fulfilled such infection m i g h t not have arisen. F o r a variety of reasons m a n y of these rules were not obeyed. I n m o r e than one hospital, in spite of the great efforts made, it has not been practicable to finish
PUBLIC HEALTH, May, 1945 the cleaning at an early h o u r in the m o r n i n g owing to the shortage of maids, so that dressings m a y begin shortly after sweeping and dusting are f i n i s h e d ; or, as we have observed on several occasions, dusting and dressings may go on together. W e have rarely seen a t e a m working at dressings, b u t only a single nurse. T h e n o n - t o u c h t e c h n i q u e usually collapses in these circumstances. E q u i p m e n t has been inadequate and not always f r o m shortage of supply, as the ward staffs complain of inadequate issue of forceps and other instruments even w h e n these are obtainable. Traffic in the ward is not avoided, or shall I say" unavoidable. T h i s is especially true in our main teaching hospital, in which several firms u n d e r different surgeons share a ward, and where ward rounds and dressings often coincide. T h e medical staffs and students w h o c o m e and go have little respect for dressings. T h e masks are usually a single layer of linen. M a n y of the medical m e n do not u s e masks in the ward, so that it is hardly possible to convince the nursing staff or students that t h e y are necessary. M y conclusion is that w h e r e conditions such as I have m e n t i o n e d prevail the dressing of burns and other open wotmds in wards is dangerous. T o discipline a large and busy ward so as to make it safe would in some instances appear so formidable a task that an alternative solution would seem the proper one - - n a m e l y , that dressings should not be done in the wards. A r o o m approaching as near as possible to the theatre b u t without elaborate e q u i p m e n t should be set aside. I n practice, this has proved satisfactory. Surgeons agree that operations carried out u n d e r theatre conditions carry l i t t l e risk of infection, find t h e aim should be to approach such theatre conditions for the dressing of serious open wounds. In this connection I w o u l d point out the need for supervision in the casualty departments and m i n o r operating theatre, where laxity in technique leads not infrequently to serious trouble. Local Application of Penicillin I f it is possible to fulfil the rules of asepsis which have been formulated, then u n d e r g o o d conditions ward dressings can be carried out in comparative safety. T h i s is illustrated by the experience at a hospital receiving wounded. I n the early part of last year it was announced that penicillin w o u l d be available for the treatment: of w o u n d e d from the anticipated battle in Europe, but owing to the shortage of supplies it was r e c o m m e n d e d that where possible treatment should be local. It was decided, therefore, to use local penicillin t r e a t m e n t for c o m p o u n d fractures, and a ward was allotted for this p u r pose and the staff specially instructed in the prevention of hospital infection. Results in that ward were excellent. T h e n u m b e r of w o u n d e d a d m i t t e d t o hospital, however, was great, and surgeons working in other wards wished to use penicillin, w h i c h they did. I n one of these wards, where the staff were fewer, relative to the n u m b e r of patients, and had not b e e n s p e c i a l l y trained, and where precautions for asepsis were lax, the incidence of gram-negative infection occurring in hospital was extremely high~ causing suppuration and apparent delay in healing. It is interesting to contrast two of the wards in w h i c h penicillin was used and where the staff had not been specially trained. I n one of these the surgeon, during the first two or three weeks, took his patients to the operating theatre for the dressings. Dressings were usually don~ only once a week. T h e incidence of infection was lower than in a second ward w h e r e dressings were carried out in the ward as frequently as every two or three days, or even every day, and where it was the habit of the sister to order the dressings to be done on all patients unless she had ihstructions to the contrary. A similar experience w i t h gram-negative infection with a trained and untrained staff is recorded by McKissock, L o g u e and Bartholomew (1944). W i t h a specially trained staff local penicillin in neurosurgery was safe, but under less favourable conditions, with a staff not so trained, hospital infection was frequent. I t may well be a s k e d : Is the trouble and expense w o r t h while ? Local or general chemotherapy can be used to p r e v e n t or treat streptococcal and staphylococcal infection, so w h y w o r r y ? F e w people seem to have regarded gram-negative organisms in a w o u n d ~s anything m o r e than a nuisance.
91
PUBLIC: HEALTH, May, 1945 H i t h e r t o , however, w h e n w o u n d i n f e c t i o n h a s b e e n of a m i x e d t y p e t h e streptococci a n d staphylococci h a v e b e e n b l a m e d for all t h e mischief, a n d t h e cotiforms a n d p y o c y a n e u s n o t b l a m e d ; t h e latter h a v e even b e e n praised. T h e selective r e m o v a l of streptococci a n d staphylococci b y penicillin, however, has s h o w n t h a t t h e r e s i d u a l g r a m - n e g a t i v e i n f e c t i o n m a y cause s u p p u r a t i o n a n d delay in healing, at least in surface w o u n d s w i t h loss of skin. M o r e o v e r , t h e i n t r o d u c t i o n of penicillin has created n e w p r o b l e m s in h o s p i t a l infection. Penicillin h a s n o effect o n g r a m - n e g a t i v e bacilli, a n d s o m e t i m e s seems to e n c o u r a g e t h e i r growth, especially in t h e case of Ps. pyocyanea. F o r certain c o n d i t i o n s - - n a m e l y , m e n i n g i t i s , e m p y e m a , a n d septic a r t h r i t i s in a d d i t i o n to w o u n d s - - p e n i c i l l i n is u s e d locally. R e p l a c e m e n t of a streptococcal or p n e u m o c o c c a l m e n i n g i t i s b y one d u e to Ps. pyocyanea is a definite risk. A l r e a d y some s u r g e o n s are d i s m a y e d because, h a v i n g quickly overcome, b y injections of penicillin, a n e m p y e m a d u e to streptococci, staphylococci or p n e u m o c o c c i , t h e y are left w i t h one d u e to B. coli or Ps. pyocyanea. T h i s f o r m of hospital infection is serious, a n d d e m a n d s t h a t rigid aseptic t e c h n i q u e b e p e r f o r m e d . I a m n o t i m p l y i n g t h a t before penicillin was i n t r o d u c e d h o s p i t a l infection did n o t o c c u r in e m p y e m a t a . T h e t u b e - a n d , f u n n e l m e t h o d of w a s h i n g o u t a pleural cavity was a c o m m o n source of such infection. T h i s m e t h o d has b e e n c o n d e m n e d b u t is still used. Conclusion T h e p r o b l e m of surgical infection in hospitals is still a n i m p o r t a n t one. O n t h e clinical side it does n o t s e e m to b e a n y o n e ' s j o b to a t t e n d to its p r e v e n t i o n . S t u d e n t s a n d n u r s e s a p p e a r to receive i n a d e q u a t e i n s t r u c t i o n in t h e subject. I f hospital infection is to b e t a k e n seriously it m u s t b e t h e d u t y of s o m e o n e in a u t h o r i t y to supervise m e t h o d s a n d teaching. W a r d t e c h n i q u e in general n e e d s to b e i m p r o v e d , or special r o o m s for w o u n d d r e s s i n g provided. REFERENCES COLEmtOOK, L. (1944). M.R.C. Special Report. No. 249. McKIssocK, W., LOGUE, V., and BARTh~OLOMEW,I. (1944). Brit. reed. f t , 2, 551
TUBERCULIN
PATCH
TEST
By W I L L I A M CANDIB, B.A., L.R.C.P. ~ S.ED.,
Formerly Physician to Elmfield Receiving Home, Manchester I n t h e past few years m a n y investigations have b e e n carried o u t w i t h t h e p a t c h test i n a n a t t e m p t to test its w o r t h i n relat i o n tO t h e M a n t o u x test. M o s t w o r k e r s i n this c o u n t r y (Hart, 1938; A n t h o n y , 1 9 3 9 ; Court, 1939) f o u n d t h e p a t c h test as reliable as t h e M a n t o u x in testing t h e average hospital a n d school child. T h e s a m e results are c l a i m e d b y A m e r i c a n workers (Pearse, Fried, a n d G l o v e r , 1 9 4 0 ; R e i s m a n a n d G r o z i n , 1941). B r o w n (1939) f o u n d t h e p a t c h specific b u t less sensitive t h a n t h e M a n t o u x test. A n z e n (1937) s h o w e d t h e p a t c h t e s t was reliable in o l d e r c h i l d r e n . C o m p a r a t i v e l y little work has b e e n d o n e in c h e c k i n g t h e efficiency o f the p a t c h t e s t in cases k n o w n to be infected. Reisman and Grozin (1941) t e s t e d 1,000 c h i l d r e n of t h e h o s p i t a l class, b u t only eleven were t u b e r c u l o u s . I t was originally p l a n n e d in this investigation to c o m p a r e results o n M a n t o u x t e s t i n g w i t h t h o s e of p a t c h testing in 200 c h i l d r e n of h o s p i t a l class. I n cases k n o w n to b e t u b e r c u l o u s t h e M a n t o u x test was a l m o s t c o n s i s t e n t l y positive, b u t results w i t h t h e p a t c h test s h o w e d a c o n s i d e r a b l y smaller p e r c e n t a g e of positive reactors. A l t h o u g h t h i s investigation was n o t c o m p l e t e d , results w i t h t h e p a t c h t e s t i n t u b e r c u l o u s cases were d i s a p p o i n t i n g . T h e d i s a p p o i n t i n g feature did n o t a p p e a r to be a q u e s t i o n of p s e u d o - r e a c t i o n s ( V o l m e r a n d Ripps, 1943) i n M a n t o u x t e s t i n g a n d n o t in p a t c h testing, n o r d i d it a p p e a r t o b e a q u e s t i o n of allergy or d i m i n i s h e d sensitivity d u e to a d v a n c e d lesions or m o r i b u n d states (Hayes et al., 1937). T h e slightest a b r a s i o n of skin greatly increases t h e a b s o r p tive capacity (Schalek, 1 9 3 1 ; S u t t o n a n d S u t t o n , 1 9 3 5 ) . . I t was t h u s d e c i d e d to scarify t h e skin superficially a n d to a p p l y t h e p a t c h test to see i f b e t t e r results c o u l d n o t b e o b t a i n e d i n p a t i e n t s k n o w n to b e t u b e r c u l o u s . S i n c e t h e patch" test, it is stated, is e q u i v a l e n t in sensitiveness to t h e I/1,000 dose
of the M a n t o u x test, t h e i m p o r t a n c e o f p e n e t r a t i o n of this small dose s e e m s logical. V o l m e r a n d R i p p s (1943) state t h a t only small a m o u n t s of t u b e r c u l i n are a b s o r b e d p e r c u t a n e o u s l y ; b u t this is sufficient to b r i n g f o r t h a positive reaction in a n i n f e c t e d p e r s o n w i t h t u b e r c u l i n allergy. L o v e t t (1929) s h o w e d t h a t r e m o v a l of oily secretions b y r u b b i n g t h e skin w i t h e t h e r resulted in m o r e accurate results w i t h t h e p a t c h test. T h i s was m e r e l y a step to e n s u r e m o r e i n t i m a t e contact o f skin w i t h t u b e r c u l i n . T h e P i r q u e t t e s t (1907) of b o r i n g t h r o u g h t h e skin surface a n d t h e n a p p l y i n g old t u b e r c u l i n was f o r m e r l y in use as a m e t h o d of i n t r o d u c i n g it i n t o t h e d e e p e r layers of the skin. T h e later modification of t h e P i r q u e t test consists of a n a p p l i c a t i o n of old t u b e r c u l i n to superficial scarification (billey, 1941). T h e m e t h o d t h a t is to b e d e s c r i b e d is also a m o d i f i c a t i b n of P i r q u e t ' s test, b u t t h e p a t c h test is u s e d instead of old t u b e r c u l i n (modified p a t c h test). Material and M e t h o d s
A n area of skin was cleansed w i t h e t h e r - m e t h , e i t h e r anteriorly. o v e r t h e u p p e r p a r t of t h e s t e r n u m or posteriorly j u s t lateral to t h e u p p e r dorsal spine. A f t e r evaporation, t h e u p p e r m o s t p a r t of a t u b e r c u l i n p a t c h test (¼ in.) was stuck o n to t h e skin in t h e same area. T h e r e m a i n d e r of t h e u p p e r p a r t of t h e p a t c h test was t h e n b r o u g h t t o w a r d t h e s k i n to e s t i m a t e w h e r e t h e t u b e r c u l i n s q u a r e w o u l d f a l l ; a s c r a t c h was m a d e on a c o r r e s p o n d i n g area of t h e skin, a n d this p a r t of t h e p a t c h was pressed to it. T h e same was d o n e for t h e control s q u a r e a n d t h e n t h e l o w e r square. O n e o r two h o r i z o n t a l o r vertical scratches, v a r y i n g in l e n g t h f r o m ~ to ¼ in., were m a d e w i t h a small h y p o d e r m i c needle. A separate needle was u s e d for each p a t i e n t ; t h e needles were sterilised a n d k e p t in e t h e r m e t h . before use. P a r t i c u l a r care was t a k e n to see t h a t the b a r r e l of each n e e d l e was dry. A second p a t c h was t h e n placed in same cleansed area alongside of t h e scarified patch. N o scarification w a s d o n e here. T h e m o d i f i e d or scarified p a t c h was always d o n e o n t h e left side, a n d t h e o t h e r p a t c h o n the right. T h i s p r e v e n t e d c o n f u s i o n in case the scarified area c o u l d n o t b e identified. B o t h tests were d o n e o n 229 patients, v a r y i n g i n age f r o m n i n e m o n t h s to 19 years. Results were read 72 h o u r s later, a m e t h o d s u g g e s t e d b y T a y l o r (1939). A positive r e a c t i o n was one w h i c h s h o w e d a n area of i n d u r a t e d redness a n d o e d e m a at least 7"5 ram. i n diameter, w i t h or w i t h o u t p a p u l e s a n d vesicles. T h e m i d d l e p o r t i o n o f t h e p a t c h acted as a control for b o t h tests. Results
O n t h e basis of diagnosis, a h i s t o r y as to contact a n d react i o n of e i t h e r test, cases are divided into the following t h r e e groups :Group 1 . - - A l l e r g i c a n d n o n - a l l e r g i c reactors w i t h t u b e r c u l o u s lesions. T h i s g r o u p i n c l u d e d 114 c h i l d r e n : 106 ( 9 3 % ) were positive to t h e modified p a t c h test, a n d eight ( 7 % ) were negative. W i t h the u n a l t e r e d patch, 62 (54-4%) were positive a n d 52 ( 4 5 - 6 % ) negative. (See T a b l e I.) Group 2 . - - A l l e r g i c reactors w i t h o u t t u b e r c u l o u s lesions. N o t u b e r c u l o u s lesions were p r e s e n t in this category, b u t allergic reactions were recorded. A h i s t o r y of contact was p r e s e n t in s o m e o f t h e s e cases. T h e r e were 14 in t h e entire g r o u p ; every case was positive to t h e m o d i f i e d p a t c h t e s t ; w i t h t h e p a t c h test, five were positive a n d n i n e negative. (See T a b l e II.) Group 3 . - - T h e n o r m a l group. T h e r e w e r e 101 cases i n this s e r i e s . E v e r y child was negative to b o t h tests ; four o f t h e cases i n c l u d e d i n this series were definite contacts, b u t gave n o reaction to e i t h e r test. ( N o table is s h o w n for this group.) I n T a b l e I, Case No. 103 was t h e o n l y reactor to t h e p a t c h test t h a t d i d n o t react to t h e m o d i f i e d patch. Case No. 41, i n t h e same table, was negative to b o t h tests d u r i n g t h e rash s t a g e of measles, b u t b e c a m e positive s h o r t l y after d i s a p p e a r a n c e of t h e r a s h ( w i t h b o t h tests). Case No. 1 t 4 ( T a b l e I) w a s d i a g n o s e d as spinal caries, a n d associated w i t h ~this was a m o d e r a t e b u t w i d e s p r e a d iehthyosis. T w o p a t c h e s were a p p l i e d i n t h e usual way i n a particularly r o u g h area of skin ; b o t h tests w e r e negative. T h e s a m e p r o c e d u r e was repeated i n a c o m p a r a t i v e l y less t h i c k e n e d areta a n d scarification was m a d e m o r e i n t e n s e ; t h e m o d i f i e d p a t c h was positive, the p a t c h test negative.
Inoculation Infection I n o c u l a t i o n infection affects n o t o n l y school i m m u n i s a t i o n clinics, b u t also hospital w a r d s a n d o u t - p a t i e n t clinics. A n u m b e r of o u t b r e a k s of infection w i t h h a e m o l y t i c streptococci, S t a p h . aureus a n d even t u b e r c l e bacilli, at t h e i n o c u l a t i o n site after injection w i t h d i p h t h e r i a p r o p h y l a c t i c A . P . T . , have c o m e to o u r notice d u r i n g t h e last t h r e e years. T h e r e is u r g e n t n e e d for a radical o v e r h a u l of t h e t e c h n i q u e of sterilisarion, use, a n d care of syringes, a n d the t e a c h i n g of careful a n d foolp r o o f m e t h o d s to m e d i c a l s t u d e n t s a n d n u r s i n g staff. I t is strange how, w h e n q series of severe reactions, s o m e t i m e s a c c o m p a n i e d b y abscess formation, occurs in a d i p h t h e r i a i m m u n i s a t i o n clinic o n a particular occasion t h e cause of the reaction is n e a r l y always a t t r i b u t e d to t h e A . P . T . , w h e n p r o b a b l y the i n o c u l a t i o n t e c h n i q u e is at fault. That the sterilisation, care, a n d use of t h e l u m b a r p u n c t u r e n e e d l e a n d of syringes u s e d for spinal analgesia also n e e d a t t e n t i o n has b e e n s h o w n b y S m i t h a n d S m i t h (1941), w h o r e p o r t e d a hospital o u t b r e a k of m e n i n g i t i s caused b y infection f r o m " sterile " w a t e r in w h i c h needles a n d syringe were placed. E v a n s (1945) has also r e c o r d e d two fatal cases of Ps. p y o c y a n e a m e n i n g i t i s after spinal anaesthesia in h o s p i t a l ; a n d C a i r n s (1945) has b e e n i m p r e s s e d b y t h e n u m b e r of cases of m e n ingitis after l u m b a r p u n c t u r e . A n o t h e r d i s t u r b i n g indication of t h e failure of c u r r e n t syringe t e c h n i q u e is the a c c u m u l a t i n g evidence t h a t t h e s e are n o t t h e only inoculations w h i c h h a v e b e e n followed b y u n t o w a r d results. T h e association of h e p a t i n s a n d j a u n d m e w t t h t h e a d m m ~ s t r a t m n of insulin ( G r a h a m ,
by 1938), t h e gold t r e a t m e n t of a r t h r i t i s (Hartfall, G a r l a n d , a n d Gotdie, 1937 ; Hartfall, 1944), a n d t h e t r e a t m e n t of syphilis w i t h organic arsenicals ( M a c C a l l u m , 1 9 4 3 ; S a l a m a n , K i n g , Williams, a n d Nicol, 1944 ; S h e e h a n , t944) indicate t h a t t h e increasingly w i d e s p r e a d use of biologicals a n d d r u g s a d m i n i s t e r e d b y syringe accentuates the risks o f infection. F u l l precautions s h o u l d be t a k e n b y the a d o p t i o n of a careful a n d rigid t e c h n i q u e of syringe sterilisation.
Conclusion I n conclusion, I r e c o m m e n d t h e practice of t h e p r o c e d u r e s p r o p o s e d in M . R . C . W a r M e m o s . No. 6 (1941) o n T h e P r e vention o f H o s p i t a l I n f e c t i o n o f Wounds,. a n d No. 11 (1944) o n T h e C o n t r o l o f C r o s s - I n f e c t i o n in H o s p i t a l s . I have o m i t t e d to lay a n y stress on t h e p a r t p l a y e d b y t h e bacteriologist in t h e p r e v e n t i o n a n d control of h o s p i t a l infection, b e c a u s e his r61e is ancillary to a d m i n i s t r a t i v e p r o c e d u r e s a n d to t h e ritual o f t e c h n i q u e a n d n u r s i n g practice. B u t I feel t h a t m o r e use s h o u l d be i n a d e of his k n o w l e d g e a n d experience t h a n has h i t h e r t o b e e n t h e case. H e can b e as o b s e r v a n t a n d critical as t h e s u r g e o n in t h e detection o f flaws i n aseptic t e c h n i q u e , a n d in a d v i s i n g o n p r o c e d u r e s w h i c h p e r h a p s c o m e tess t h a n they s h o u l d w i t h i n t h e direct p u r v i e w o f the p h y s i c i a n a n d surgeon. I lay stress o n t h e i m p o r t a n c e of b e t t e r e d u c a t i o n of the n u r s e a n d medical s t u d e n t in t h e principles a n d practice of p r e v e n t i v e m e a s u r e s in t h e i r a p p l i c a t i o n to hospital practice. P~EFERENCES Aerobiology. (1942). Washington D.C. American Association for the Advance-
ment of Science. ALLISON, V. D. (1942). Control of the Common Fevers. p. 57, Lancet, 1942. American Hospital Association, Chicago, Illinois. (1940).~ Bulletin No. 203. Ultra-violet Rays as a Sterilisation Agent in Hospitals. ANDR~'ES, C.H. (1940). Lancet, 2, 770. BOURDILLON,R. B., LIDWELL,O. M., and LOVELOCK,J E. (1942). Brit. med, ft., 1, 42. BUCHBINDER,L. (1942). Aeroblology. Washington, D.C. American Association for Advaneeanentof Science. p. 267. BULLOUGtt,W.A. (1942). Proc. roy. Soc. Med., 35, 371. CAIE2~S,H. (1945). Brit. reed. ft., 1, 379. ELCOCK, C.E. (1942). Proc. roy. Soc. Med., 3S, 359. EVANS, F. T. (1945). Lancet, 1, 115. GARROD,L.P. (1944). Brit. meal. ft., 1, 245. GI~HAM, G. (1938). Lancet, 2, 1. HARTFALL,S.J. (1944). Ibid., 2, 358. --, GARLAND, H. G., and GOLD1E, W. (1937). lbld., 2, 838. HOLLAENDER,A. (1943). Amer. J. publ. Hlth., 33, 980. LOVELOCK,J. E., L~iDWELL,O. M., and RAYMOND,W. F. (/944). Nature, 153, 20. MACCALLUM,F.O. (1943). Brit. g, verier. Dis., 19, 63. MCCLtmE, W.B. (1944). Canad. ft. publ. Hlth., 35, 380. M.R.C. (1941). The Prevention of Hospital Infection of Wounds. War Memo. No. 6. ~.~t(1944)" The Control of Cross-infection in Hospital Wards. War Memo. No. MITMAN, M. (1945). Brit. reed. J., 1, 71. ROBERT$ON,O. H., BIGO, E., PUCK, T. T., and MILLER, B. F. (1942)..~. exp. Med., ~S, 593. •, HAMBURGER,M., LOOSLI, C. G., PUCK,T. T., LEMON,H. M., and WIs~, H. (1944)..% Amer. reed. Ass., 126, 993. SALAMAN,M. S., KING, A. J., WILLIAMS,D. I., and NICOL, C.S. (1944). Lancet, Z, 7. SHEEHAN,H.L. (1944). ].bid., 2, 8. SMITH, W., and SMITH, M. M. (1941). Ibid., 2, 783. VANDEN ENDE, M., and THOMAS,J.C. (1941). Ibid., 2, 755. WE~t.LS,~V. F., WELLS,M. W., and WILDER,T.S. (1942). Amer. ff. Hyg., 3~, 07. WRIGHT, J., CRUICKSHANK,R., and GUNN, V¢. (1944). Brit. med. ft., 1, 611.
PREVENTION
OF
HOSPITAL WOUNDS
INFECTION
OF
B y J. GOUGH, M.D., L e c t u r e r in P a t h o l o g y , W e l s h N a t i o n a l S c h o o l o f M e d i c i n e
I n t h e early m o n t h s of t h e w a r t h e m e m b e r s o f t h e p a t h o l o g y staff of t h e W e l s h N a t i o n a l School of M e d i c i n e t r i e d to increase t h e i n t e r e s t of h o s p i t a l authorities in t h e p r o b l e m of hospital infection. T h e h o s p i t a l medical a u t h o r i ties w h o were a p p r o a c h e d agreed to p u t into o p e r a t i o n as far as possible t h e r e c o m m e n d a t i o n s w h i c h are i n c l u d e d in t h e M.R.C. publication The Prevention of Hospital Infection of W o u n d s w h i c h a p p e a r e d in 1941. A f t e r four years we are i n a p o s i t i o n to j u d g e h o w m a n y of t h e s e r e c o m m e n d a t i o n s were actually p u t into effect, or, in s o m e instances, h o w few. B u t w e c a n n o t say t h a t we are i n a p o s i t i o n to j u d g e w h a t benefits, if a n y , have occurred. T h e m a i n rules c o n c e r n e d a t e a m m e t h o d for surgical dressing, n o n - t o u c h f t e c h n i q u e , efficient m a s k i n g , the oiling of floors, a n d efficient m e t h o d s for t h e sterilisation of i n s t r u m e n t s . These were directed
90 particularly to prevent streptococcal infection. S u c h infection was expected in war wounds if the experience of the last war was to be repeated. We have seen, however, extremely little streptococcal infection. S o m e cases returning from N o r t h Africa in 1942-43 showed it, b u t practically none of the w o u n d e d f r o m E u r o p e since the s u m m e r of 1944 have had this infection. W e cannot say w h e t h e r the absence of streptococcal infection is due to the better surgical technique in hospitals, or to the better t e c h n i q u e in the field, or to chemot h e r a p y - f o r there has been a liberal and almost universal use of sulphonamides or p e n i c i l l i n - - o r to all together. A l t h g u g h streptococcal infections have been few and staphylococcal infections also comparatively rare, infections with gramnegative bacilli have been quite c o m m o n and have often been acquired in h o s p i t a l ; and it is mainly abbut such infections that I wish to speak. At the present t i m e the incidence of such infections appears to be a better criterion of hospital infection. Hospital Infection with Gram-negatlve Bacilli I came into contact w i t h this f o r m of hospital infection w h e n working with Dr. Dillwyn T h o m a s at Sully. H e had been draining tuberculous cavities by m e a n s of a catheter inserted t h r o u g h the chest wall (Monaldi technique). T u b e r culous cavities in their natural state are never secondarily infected, but after drainage they usually become so. W e m e t a variety of organisms, but most c o m m o n l y Ps. pyocyanea. I n o r d e r to try out chemical substances w h i c h could control this infection, I looked for pyocyanens infections in other hospitals, especially in surface wounds and ulcers w h i c h would be accessible to treatment and where results could be judged. I n the several hospitals where I looked for pyocyaneus infection, there was ample material. T h e s e included general hospitals, and hospitals w h e r e military patients w i t h recent and old wounds were being treated. It was obvious that m a n y cases of burns and m a n y surface wounds with skin loss, including c o m p o u n d fractures, became infected with gram-negative organisms and especially pyocyaneus while in general hospitals. S o m e had o t h e r infections as well. Investigations were carried out to see how far it would be possible to prevent infection in burns as Colebrook and others had done. Bnrils
I started by treating the burns in a casualty department. Operating theatre conditions were used ; , no gloves were worn, but a strict n o n - t o u c h technique was employed. T h e dressings were changed as infrequently as possible, and in spite of the fact that these patients were treated at h o m e and ret u r n e d for dressings about every five days the incidence of infection in 70 cases was very low, and no pyocyaneus infection occurred in any of them. P o s s i b l ~ these results contrasted with those of patients in the wards because they were comparatively m i n o r burns, b u t in April, May, and June of 1944, w h e n hospital beds for civilians were scarce, we treated as out-patients m a n y w h o in normal times w o u l d have been admitted. Again, the incidence of infection was low and no pyocyaneus infection occurred. Since that t i m e m a n y in-patients have been treated likewise. W h e n the technique has been rigidly followed, and provided the dressings have been infrequent and carried out u n d e r theatre conditions, the results have on the whole been satisfactory. It has not been possible to p r e v e n t infection in deep burns w h e n sloughing of the whole skin thickness occurred, but there has been great i m p r o v e m e n t in the results in superficial ones. F o r m e r l y , w h e n dressings had been done in wards without rigid technique, and especially if they had been done frequently, infection became c o m m o n and the results indifferent or poor. Burns of a m i n o r degree which should have healed in ten days had been converted as a result of infection into granulating areas requiring weeks to heat, and often requiring skin-grafting. I f the rules for w o u n d dressings set out in the M . R . C . m e m o r a n d u m could have been fulfilled such infection m i g h t not have arisen. F o r a variety of reasons m a n y of these rules were not obeyed. I n m o r e than one hospital, in spite of the great efforts made, it has not been practicable to finish
PUBLIC HEALTH, May, 1945 the cleaning at an early h o u r in the m o r n i n g owing to the shortage of maids, so that dressings m a y begin shortly after sweeping and dusting are f i n i s h e d ; or, as we have observed on several occasions, dusting and dressings may go on together. W e have rarely seen a t e a m working at dressings, b u t only a single nurse. T h e n o n - t o u c h t e c h n i q u e usually collapses in these circumstances. E q u i p m e n t has been inadequate and not always f r o m shortage of supply, as the ward staffs complain of inadequate issue of forceps and other instruments even w h e n these are obtainable. Traffic in the ward is not avoided, or shall I say" unavoidable. T h i s is especially true in our main teaching hospital, in which several firms u n d e r different surgeons share a ward, and where ward rounds and dressings often coincide. T h e medical staffs and students w h o c o m e and go have little respect for dressings. T h e masks are usually a single layer of linen. M a n y of the medical m e n do not u s e masks in the ward, so that it is hardly possible to convince the nursing staff or students that t h e y are necessary. M y conclusion is that w h e r e conditions such as I have m e n t i o n e d prevail the dressing of burns and other open wotmds in wards is dangerous. T o discipline a large and busy ward so as to make it safe would in some instances appear so formidable a task that an alternative solution would seem the proper one - - n a m e l y , that dressings should not be done in the wards. A r o o m approaching as near as possible to the theatre b u t without elaborate e q u i p m e n t should be set aside. I n practice, this has proved satisfactory. Surgeons agree that operations carried out u n d e r theatre conditions carry l i t t l e risk of infection, find t h e aim should be to approach such theatre conditions for the dressing of serious open wounds. In this connection I w o u l d point out the need for supervision in the casualty departments and m i n o r operating theatre, where laxity in technique leads not infrequently to serious trouble. Local Application of Penicillin I f it is possible to fulfil the rules of asepsis which have been formulated, then u n d e r g o o d conditions ward dressings can be carried out in comparative safety. T h i s is illustrated by the experience at a hospital receiving wounded. I n the early part of last year it was announced that penicillin w o u l d be available for the treatment: of w o u n d e d from the anticipated battle in Europe, but owing to the shortage of supplies it was r e c o m m e n d e d that where possible treatment should be local. It was decided, therefore, to use local penicillin t r e a t m e n t for c o m p o u n d fractures, and a ward was allotted for this p u r pose and the staff specially instructed in the prevention of hospital infection. Results in that ward were excellent. T h e n u m b e r of w o u n d e d a d m i t t e d t o hospital, however, was great, and surgeons working in other wards wished to use penicillin, w h i c h they did. I n one of these wards, where the staff were fewer, relative to the n u m b e r of patients, and had not b e e n s p e c i a l l y trained, and where precautions for asepsis were lax, the incidence of gram-negative infection occurring in hospital was extremely high~ causing suppuration and apparent delay in healing. It is interesting to contrast two of the wards in w h i c h penicillin was used and where the staff had not been specially trained. I n one of these the surgeon, during the first two or three weeks, took his patients to the operating theatre for the dressings. Dressings were usually don~ only once a week. T h e incidence of infection was lower than in a second ward w h e r e dressings were carried out in the ward as frequently as every two or three days, or even every day, and where it was the habit of the sister to order the dressings to be done on all patients unless she had ihstructions to the contrary. A similar experience w i t h gram-negative infection with a trained and untrained staff is recorded by McKissock, L o g u e and Bartholomew (1944). W i t h a specially trained staff local penicillin in neurosurgery was safe, but under less favourable conditions, with a staff not so trained, hospital infection was frequent. I t may well be a s k e d : Is the trouble and expense w o r t h while ? Local or general chemotherapy can be used to p r e v e n t or treat streptococcal and staphylococcal infection, so w h y w o r r y ? F e w people seem to have regarded gram-negative organisms in a w o u n d ~s anything m o r e than a nuisance.
91
PUBLIC: HEALTH, May, 1945 H i t h e r t o , however, w h e n w o u n d i n f e c t i o n h a s b e e n of a m i x e d t y p e t h e streptococci a n d staphylococci h a v e b e e n b l a m e d for all t h e mischief, a n d t h e cotiforms a n d p y o c y a n e u s n o t b l a m e d ; t h e latter h a v e even b e e n praised. T h e selective r e m o v a l of streptococci a n d staphylococci b y penicillin, however, has s h o w n t h a t t h e r e s i d u a l g r a m - n e g a t i v e i n f e c t i o n m a y cause s u p p u r a t i o n a n d delay in healing, at least in surface w o u n d s w i t h loss of skin. M o r e o v e r , t h e i n t r o d u c t i o n of penicillin has created n e w p r o b l e m s in h o s p i t a l infection. Penicillin h a s n o effect o n g r a m - n e g a t i v e bacilli, a n d s o m e t i m e s seems to e n c o u r a g e t h e i r growth, especially in t h e case of Ps. pyocyanea. F o r certain c o n d i t i o n s - - n a m e l y , m e n i n g i t i s , e m p y e m a , a n d septic a r t h r i t i s in a d d i t i o n to w o u n d s - - p e n i c i l l i n is u s e d locally. R e p l a c e m e n t of a streptococcal or p n e u m o c o c c a l m e n i n g i t i s b y one d u e to Ps. pyocyanea is a definite risk. A l r e a d y some s u r g e o n s are d i s m a y e d because, h a v i n g quickly overcome, b y injections of penicillin, a n e m p y e m a d u e to streptococci, staphylococci or p n e u m o c o c c i , t h e y are left w i t h one d u e to B. coli or Ps. pyocyanea. T h i s f o r m of hospital infection is serious, a n d d e m a n d s t h a t rigid aseptic t e c h n i q u e b e p e r f o r m e d . I a m n o t i m p l y i n g t h a t before penicillin was i n t r o d u c e d h o s p i t a l infection did n o t o c c u r in e m p y e m a t a . T h e t u b e - a n d , f u n n e l m e t h o d of w a s h i n g o u t a pleural cavity was a c o m m o n source of such infection. T h i s m e t h o d has b e e n c o n d e m n e d b u t is still used. Conclusion T h e p r o b l e m of surgical infection in hospitals is still a n i m p o r t a n t one. O n t h e clinical side it does n o t s e e m to b e a n y o n e ' s j o b to a t t e n d to its p r e v e n t i o n . S t u d e n t s a n d n u r s e s a p p e a r to receive i n a d e q u a t e i n s t r u c t i o n in t h e subject. I f hospital infection is to b e t a k e n seriously it m u s t b e t h e d u t y of s o m e o n e in a u t h o r i t y to supervise m e t h o d s a n d teaching. W a r d t e c h n i q u e in general n e e d s to b e i m p r o v e d , or special r o o m s for w o u n d d r e s s i n g provided. REFERENCES COLEmtOOK, L. (1944). M.R.C. Special Report. No. 249. McKIssocK, W., LOGUE, V., and BARTh~OLOMEW,I. (1944). Brit. reed. f t , 2, 551
TUBERCULIN
PATCH
TEST
By W I L L I A M CANDIB, B.A., L.R.C.P. ~ S.ED.,
Formerly Physician to Elmfield Receiving Home, Manchester I n t h e past few years m a n y investigations have b e e n carried o u t w i t h t h e p a t c h test i n a n a t t e m p t to test its w o r t h i n relat i o n tO t h e M a n t o u x test. M o s t w o r k e r s i n this c o u n t r y (Hart, 1938; A n t h o n y , 1 9 3 9 ; Court, 1939) f o u n d t h e p a t c h test as reliable as t h e M a n t o u x in testing t h e average hospital a n d school child. T h e s a m e results are c l a i m e d b y A m e r i c a n workers (Pearse, Fried, a n d G l o v e r , 1 9 4 0 ; R e i s m a n a n d G r o z i n , 1941). B r o w n (1939) f o u n d t h e p a t c h specific b u t less sensitive t h a n t h e M a n t o u x test. A n z e n (1937) s h o w e d t h e p a t c h t e s t was reliable in o l d e r c h i l d r e n . C o m p a r a t i v e l y little work has b e e n d o n e in c h e c k i n g t h e efficiency o f the p a t c h t e s t in cases k n o w n to be infected. Reisman and Grozin (1941) t e s t e d 1,000 c h i l d r e n of t h e h o s p i t a l class, b u t only eleven were t u b e r c u l o u s . I t was originally p l a n n e d in this investigation to c o m p a r e results o n M a n t o u x t e s t i n g w i t h t h o s e of p a t c h testing in 200 c h i l d r e n of h o s p i t a l class. I n cases k n o w n to b e t u b e r c u l o u s t h e M a n t o u x test was a l m o s t c o n s i s t e n t l y positive, b u t results w i t h t h e p a t c h test s h o w e d a c o n s i d e r a b l y smaller p e r c e n t a g e of positive reactors. A l t h o u g h t h i s investigation was n o t c o m p l e t e d , results w i t h t h e p a t c h t e s t i n t u b e r c u l o u s cases were d i s a p p o i n t i n g . T h e d i s a p p o i n t i n g feature did n o t a p p e a r to be a q u e s t i o n of p s e u d o - r e a c t i o n s ( V o l m e r a n d Ripps, 1943) i n M a n t o u x t e s t i n g a n d n o t in p a t c h testing, n o r d i d it a p p e a r t o b e a q u e s t i o n of allergy or d i m i n i s h e d sensitivity d u e to a d v a n c e d lesions or m o r i b u n d states (Hayes et al., 1937). T h e slightest a b r a s i o n of skin greatly increases t h e a b s o r p tive capacity (Schalek, 1 9 3 1 ; S u t t o n a n d S u t t o n , 1 9 3 5 ) . . I t was t h u s d e c i d e d to scarify t h e skin superficially a n d to a p p l y t h e p a t c h test to see i f b e t t e r results c o u l d n o t b e o b t a i n e d i n p a t i e n t s k n o w n to b e t u b e r c u l o u s . S i n c e t h e patch" test, it is stated, is e q u i v a l e n t in sensitiveness to t h e I/1,000 dose
of the M a n t o u x test, t h e i m p o r t a n c e o f p e n e t r a t i o n of this small dose s e e m s logical. V o l m e r a n d R i p p s (1943) state t h a t only small a m o u n t s of t u b e r c u l i n are a b s o r b e d p e r c u t a n e o u s l y ; b u t this is sufficient to b r i n g f o r t h a positive reaction in a n i n f e c t e d p e r s o n w i t h t u b e r c u l i n allergy. L o v e t t (1929) s h o w e d t h a t r e m o v a l of oily secretions b y r u b b i n g t h e skin w i t h e t h e r resulted in m o r e accurate results w i t h t h e p a t c h test. T h i s was m e r e l y a step to e n s u r e m o r e i n t i m a t e contact o f skin w i t h t u b e r c u l i n . T h e P i r q u e t t e s t (1907) of b o r i n g t h r o u g h t h e skin surface a n d t h e n a p p l y i n g old t u b e r c u l i n was f o r m e r l y in use as a m e t h o d of i n t r o d u c i n g it i n t o t h e d e e p e r layers of the skin. T h e later modification of t h e P i r q u e t test consists of a n a p p l i c a t i o n of old t u b e r c u l i n to superficial scarification (billey, 1941). T h e m e t h o d t h a t is to b e d e s c r i b e d is also a m o d i f i c a t i b n of P i r q u e t ' s test, b u t t h e p a t c h test is u s e d instead of old t u b e r c u l i n (modified p a t c h test). Material and M e t h o d s
A n area of skin was cleansed w i t h e t h e r - m e t h , e i t h e r anteriorly. o v e r t h e u p p e r p a r t of t h e s t e r n u m or posteriorly j u s t lateral to t h e u p p e r dorsal spine. A f t e r evaporation, t h e u p p e r m o s t p a r t of a t u b e r c u l i n p a t c h test (¼ in.) was stuck o n to t h e skin in t h e same area. T h e r e m a i n d e r of t h e u p p e r p a r t of t h e p a t c h test was t h e n b r o u g h t t o w a r d t h e s k i n to e s t i m a t e w h e r e t h e t u b e r c u l i n s q u a r e w o u l d f a l l ; a s c r a t c h was m a d e on a c o r r e s p o n d i n g area of t h e skin, a n d this p a r t of t h e p a t c h was pressed to it. T h e same was d o n e for t h e control s q u a r e a n d t h e n t h e l o w e r square. O n e o r two h o r i z o n t a l o r vertical scratches, v a r y i n g in l e n g t h f r o m ~ to ¼ in., were m a d e w i t h a small h y p o d e r m i c needle. A separate needle was u s e d for each p a t i e n t ; t h e needles were sterilised a n d k e p t in e t h e r m e t h . before use. P a r t i c u l a r care was t a k e n to see t h a t the b a r r e l of each n e e d l e was dry. A second p a t c h was t h e n placed in same cleansed area alongside of t h e scarified patch. N o scarification w a s d o n e here. T h e m o d i f i e d or scarified p a t c h was always d o n e o n t h e left side, a n d t h e o t h e r p a t c h o n the right. T h i s p r e v e n t e d c o n f u s i o n in case the scarified area c o u l d n o t b e identified. B o t h tests were d o n e o n 229 patients, v a r y i n g i n age f r o m n i n e m o n t h s to 19 years. Results were read 72 h o u r s later, a m e t h o d s u g g e s t e d b y T a y l o r (1939). A positive r e a c t i o n was one w h i c h s h o w e d a n area of i n d u r a t e d redness a n d o e d e m a at least 7"5 ram. i n diameter, w i t h or w i t h o u t p a p u l e s a n d vesicles. T h e m i d d l e p o r t i o n o f t h e p a t c h acted as a control for b o t h tests. Results
O n t h e basis of diagnosis, a h i s t o r y as to contact a n d react i o n of e i t h e r test, cases are divided into the following t h r e e groups :Group 1 . - - A l l e r g i c a n d n o n - a l l e r g i c reactors w i t h t u b e r c u l o u s lesions. T h i s g r o u p i n c l u d e d 114 c h i l d r e n : 106 ( 9 3 % ) were positive to t h e modified p a t c h test, a n d eight ( 7 % ) were negative. W i t h the u n a l t e r e d patch, 62 (54-4%) were positive a n d 52 ( 4 5 - 6 % ) negative. (See T a b l e I.) Group 2 . - - A l l e r g i c reactors w i t h o u t t u b e r c u l o u s lesions. N o t u b e r c u l o u s lesions were p r e s e n t in this category, b u t allergic reactions were recorded. A h i s t o r y of contact was p r e s e n t in s o m e o f t h e s e cases. T h e r e were 14 in t h e entire g r o u p ; every case was positive to t h e m o d i f i e d p a t c h t e s t ; w i t h t h e p a t c h test, five were positive a n d n i n e negative. (See T a b l e II.) Group 3 . - - T h e n o r m a l group. T h e r e w e r e 101 cases i n this s e r i e s . E v e r y child was negative to b o t h tests ; four o f t h e cases i n c l u d e d i n this series were definite contacts, b u t gave n o reaction to e i t h e r test. ( N o table is s h o w n for this group.) I n T a b l e I, Case No. 103 was t h e o n l y reactor to t h e p a t c h test t h a t d i d n o t react to t h e m o d i f i e d patch. Case No. 41, i n t h e same table, was negative to b o t h tests d u r i n g t h e rash s t a g e of measles, b u t b e c a m e positive s h o r t l y after d i s a p p e a r a n c e of t h e r a s h ( w i t h b o t h tests). Case No. 1 t 4 ( T a b l e I) w a s d i a g n o s e d as spinal caries, a n d associated w i t h ~this was a m o d e r a t e b u t w i d e s p r e a d iehthyosis. T w o p a t c h e s were a p p l i e d i n t h e usual way i n a particularly r o u g h area of skin ; b o t h tests w e r e negative. T h e s a m e p r o c e d u r e was repeated i n a c o m p a r a t i v e l y less t h i c k e n e d areta a n d scarification was m a d e m o r e i n t e n s e ; t h e m o d i f i e d p a t c h was positive, the p a t c h test negative.