ACUTE MENINGITIS DUE TO OTHER BACTERIA
Meningitis due to pneumococcus, streptococcus, staphylococcus and H. influensscs is almost always secondary to some other focus of infection in the body, the most common situation being the paranasal air cells or the mastoid process. Should the bacteriological report incriminate one of these organisms, both sulphonamide and antibiotic therapy should be given. The treatment calls for the closest co-operation of physician, neurosurgeon and bacteriologist, and such patients should rarely be treated outside of hospital. Pneumococcal meningitis is by far the most serious form and still carries a high fatality rate. Thus prompt and rigorous treatment is especially important. The following are;the main principles of treatment;
Sulphonamides.—The dosage should be high and should be continued for ten days. Sulphadiazine or sulphadimidine should be given. The -organism isolated should be tested for its sensitivity to sulphonamides.Antibiotics.—Penicillin is the antibiotic most generally useful and is given systemically in a dose of at least 500,000 units every four hours. Intrathecal administration is usually essential, the dose being 20,000 units once daily. By giving large doses of penicillin, purulent foci can usually be brought under control without the need for immediate surgical interference. The testing of the bacterium originally isolated for sensitivity to a wide range of antibiotics is very important, especially in haemophilus and staphylococcus infections. Frequent bacteriological control of the cerebrospinal fluid during treatment is essential. Sfr.-eptomycin combined with sulphadiazine is the initial treatment of choice for H. influenza meningitis. Systemically the dose of streptomycin –is 1 to 3 g. daily for a period of five days ; intrathecally a dose of 50 to 100 mg. should be given at each lumbar puncture. Tetracycline, chloramphenicol or erythromycin may be preferred for certain patients as a result of the initial sensitivity testing, but, particularly with H. influenza strains, it is important to bear in mind not only the possibility of infection by initially resistant strains but also of the development, under treatment, of resistance to the antibiotic in use. For this reason repeated changes of treatment for " panic " reasons unsupported by precise bacteriological data are to be condemned. In guiding the patient through these hazards close co-operation with the bacteriologist is essential. Testing of the direct antibacterial activity of the cerebrospinal fluid against the organism responsible for the meningitis is a useful measure for it ensures that the parenterally administered antibiotic is reaching the meninges in adequate amounts. As a general rule antibiotic treatment should be continued for 10 days.
Relapse, Blockage, Encephalitis and Brain Abscess.—These complications are much more liable to arise from the organisms mentioned above than after meningococcal meningitis and must be kept constantly in mind. There must be no hesitation in performing lumbar, cisternal or ventricular puncture; any indication of rising intracranial pressure, especially in streptococcal infections, should raise the suspicion of abscess formation. Electro-encephalography is most valuable in confirming a suspicion of abscess and in helping to localizeit. The co-operation of the neurosurgeon is essential for success.
Wednesday, July 30, 2008
MENINGOCOCCAL MENINGITIS (Cerebrospinal Fever—Spotted Fever)
Curative Treatment.—The first essential, when meningitis is suspected, is to perform a lumbar puncture. The presence of acute bacterial infection will immediately be declared by the appearance of a turbid or purulent fluid which must be sent for bacteriological examination at once to determine the infecting bacterium. At the same time its sugar content should be estimated for this is usually reduced and the degree of reduction reflects the severity of the case.When turbid fluid has been obtained 10,000 to 20,000 units of crystalline penicillin is slowly injected intrathecally. This ensures that treatment has begun, no matter what bacteria are ultimately found to be present. At the same time a dose of 500,000 to 1,000,000 units of penicillin is given intramuscularly and a similar dosage is administered at two- to four-hourly intervals, depending on the severity of the infection.
The sulphonamides were, of course, responsible for the dramatic change in the fatality rate of meningococcal meningitis and under certain circumstances their use may still be preferred. Thus in situations where epidemic prevalence can be assessed fairly accurately but admission to hospital is impossible and medical and nursing resources are limited, sulphonamides have the advantage that they can be easily distributed and administered. A few strains of menin-gococci have now been isolated which are sulphonamide-resistant and since it is essential to begin effective chemotherapy as quickly as possible, these agents are no longer the drugs of first choice.
The single advantage of the sulphonamides is their ready transport compared with penicillin across the blood-brain barrier. Nevertheless, it is now known that when there is meningeal inflammation penicillin passes across in effective concentrations. In order to ensure that an adequate concentration is achieved, however, the dosage of penicillin should be greatly in excess of that normally used, and this is especially important at the beginning of treatment. The duration of treatment is a minimum of seven days; in the most severe cases this may be extended up to 10 or 12 days but prolonged therapy is unnecessary.
Dehydration is often present and in the most severe infections may require energetic treatment by intravenous infusions. Vomiting is often a marked feature of the early illness and, when sulphonamides were the standard method of treatment, the reduced renal flow resulting from dehydration could encourage tubular blockage. This risk does not arise with penicillin. It is important, however, to estimate the urea and electrolytes at the start of treatment and, in regard to fluid replacement, to be guided by the results obtained.
The assessment of progress is as a rule straightforward and in mild infections the obvious improvement of the patient makes special tests unnecessary. The severity of the illness is declared by the shocked state of the patient when first seen as well as by the initial features of the cerebrospinal fluid. In the most severe cases the fluid contains a large number of organisms, easily seen in a direct film, with most of them situated extracellularly. The sugar content may be less than 10 to 15 mg. per 100 ml. In such cases a lumbar puncture twenty-four hours later is prudent. When treatment has been effective, meningococci should be greatly reduced and should be mainly intracellular; in the most favourable cases indeed meningococci may not be seen. The sugar has often risen dramatically and may even approach normal levels. When this is the sequence of events further lumbar puncture is unnecessary and the progress of the infection can be gauged by the normal clinical evidence of improvement. When the fluid is still markedly turbid at this second lumbar puncture a further intrathecal injection of penicillin is indicated, and the results of bacteriological and chemical examinations obtained as quickly as possible. When the expected improvement has not occurred the systemic dose of penicillin should be given more frequently and the sensitivity of the meningococcus to different antibiotics should be assessed urgently. Daily lumbar puncture in such severe infections will be necessary until the results make it apparent that chemotherapy is being effective.
Complications.—Involvement of cranial or peripheral nerves may be expected in from 5 to 10 per cent. of cases. An unduly gloomy view of such complications is unjustified ; a considerable proportion clear up satisfactorily.
Blindness, often cortical in type, is usually permanent. Acute arthritis—a result of the initial septicaania—often declares itself after treatment has stopped. It rapidly responds to a second course of therapy.Convalescence.—The patient may be allowed out of bed towards the beginning of the third week of illness. A lumbar puncture should be performed on or about the twenty-first day of illness ; the best criteria of recovery are a normal cell count and a normal content of sugar in the fluid, which should be clear. The patient may now resume normal activities and a reasonably long holiday should be advised. Adult patients often complain of a general weakness for some time after their recovery ; their relatives often complain of the patient's easy irritability. Such changes, however, gradually disappear.
CHRONIC MENINGOCOCCAL SEPTICAEMIA
This condition is particularly to be expected during epidemics. Unfortunately, blood culture, which is the essential method of diagnosis, is not always positive. The bacteriologist should be advised regarding the type of case from which the culture has been taken. A course of sulphonamide appropriate to the age of the patient (most often an adult) should be given hereafter the patient should be observed for a few days for the recurrence of fever, headache, or skin rash.
The sulphonamides were, of course, responsible for the dramatic change in the fatality rate of meningococcal meningitis and under certain circumstances their use may still be preferred. Thus in situations where epidemic prevalence can be assessed fairly accurately but admission to hospital is impossible and medical and nursing resources are limited, sulphonamides have the advantage that they can be easily distributed and administered. A few strains of menin-gococci have now been isolated which are sulphonamide-resistant and since it is essential to begin effective chemotherapy as quickly as possible, these agents are no longer the drugs of first choice.
The single advantage of the sulphonamides is their ready transport compared with penicillin across the blood-brain barrier. Nevertheless, it is now known that when there is meningeal inflammation penicillin passes across in effective concentrations. In order to ensure that an adequate concentration is achieved, however, the dosage of penicillin should be greatly in excess of that normally used, and this is especially important at the beginning of treatment. The duration of treatment is a minimum of seven days; in the most severe cases this may be extended up to 10 or 12 days but prolonged therapy is unnecessary.
Dehydration is often present and in the most severe infections may require energetic treatment by intravenous infusions. Vomiting is often a marked feature of the early illness and, when sulphonamides were the standard method of treatment, the reduced renal flow resulting from dehydration could encourage tubular blockage. This risk does not arise with penicillin. It is important, however, to estimate the urea and electrolytes at the start of treatment and, in regard to fluid replacement, to be guided by the results obtained.
The assessment of progress is as a rule straightforward and in mild infections the obvious improvement of the patient makes special tests unnecessary. The severity of the illness is declared by the shocked state of the patient when first seen as well as by the initial features of the cerebrospinal fluid. In the most severe cases the fluid contains a large number of organisms, easily seen in a direct film, with most of them situated extracellularly. The sugar content may be less than 10 to 15 mg. per 100 ml. In such cases a lumbar puncture twenty-four hours later is prudent. When treatment has been effective, meningococci should be greatly reduced and should be mainly intracellular; in the most favourable cases indeed meningococci may not be seen. The sugar has often risen dramatically and may even approach normal levels. When this is the sequence of events further lumbar puncture is unnecessary and the progress of the infection can be gauged by the normal clinical evidence of improvement. When the fluid is still markedly turbid at this second lumbar puncture a further intrathecal injection of penicillin is indicated, and the results of bacteriological and chemical examinations obtained as quickly as possible. When the expected improvement has not occurred the systemic dose of penicillin should be given more frequently and the sensitivity of the meningococcus to different antibiotics should be assessed urgently. Daily lumbar puncture in such severe infections will be necessary until the results make it apparent that chemotherapy is being effective.
Complications.—Involvement of cranial or peripheral nerves may be expected in from 5 to 10 per cent. of cases. An unduly gloomy view of such complications is unjustified ; a considerable proportion clear up satisfactorily.
Blindness, often cortical in type, is usually permanent. Acute arthritis—a result of the initial septicaania—often declares itself after treatment has stopped. It rapidly responds to a second course of therapy.Convalescence.—The patient may be allowed out of bed towards the beginning of the third week of illness. A lumbar puncture should be performed on or about the twenty-first day of illness ; the best criteria of recovery are a normal cell count and a normal content of sugar in the fluid, which should be clear. The patient may now resume normal activities and a reasonably long holiday should be advised. Adult patients often complain of a general weakness for some time after their recovery ; their relatives often complain of the patient's easy irritability. Such changes, however, gradually disappear.
CHRONIC MENINGOCOCCAL SEPTICAEMIA
This condition is particularly to be expected during epidemics. Unfortunately, blood culture, which is the essential method of diagnosis, is not always positive. The bacteriologist should be advised regarding the type of case from which the culture has been taken. A course of sulphonamide appropriate to the age of the patient (most often an adult) should be given hereafter the patient should be observed for a few days for the recurrence of fever, headache, or skin rash.
MEASLES (Morbilli)
The measles virus is commonly spread by direct contact (droplet infection), particularly during the catarrhal stage of the illness, a stage at which measles is seldom diagnosed. Except for those who have previously suffered from the disease, susceptibility to measles appears to be practically universal. Although measles is always to be regarded seriously, it only constitutes a serious threat in the first 18 months of life when the complicating bronchopneumonia is a dangerous hazard.
In certain areas the first case of measles occurring in a household has to be notified to the Medical Officer of Health. Otherwise the disease is not notifiable. The incubation period is usually from nine to eleven days, but may vary from seven to fourteen days.
Preventive Treatment.—Passive Immunization.—An attack of measles can be prevented or modified by the intramuscular injection of an appropriate dose of gamma-globulin in the early stages of incubation. The dose of gamma-globulin cannot be stated with the accuracy associated with most biological products because the content of antibody is variable and there are minor variations in its preparation. For the child between one and three years of age the dose should be from 0-25 to 0-75 g. When given during the first few days of the incubation period such a dose will usually give complete protection, but when this is not attained, at least the subsequent attack is reduced in severity. The use of gamma-globulin should be restricted to contacts under the age of 18 months or children who are seriously debilitated, for example, after recovery from whooping-cough or pneumonia.
Active Immunisation.—Both a killed and a live attenuated virus vaccine are now available. The immunity obtained by the killed vaccine is of relatively short duration and a proportion of those inoculated with it acquire the disease at a subsequent exposure. The live attenuated virus vaccine produces a satisfactory immunity which certainly lasts for some years. The vaccine is freeze-dried and reconstituted with ro ml. of sterile distilled water before use. The injection is given subcutaneously. A proportion of the children inoculated (from 15-25 per cent.) develop moderately severe febrile reactions about a week after injection, while a few show evidence of a mild attack of measles. These reactions have been mitigated (a) by the simultaneous injection of gamma globulin and (&) by preliminary vaccination with the killed vaccine.
At present these vaccines are used mainly in those countries where the mortality from measles is high. In other communities where there are adequate standards of child health and where malnutrition is rare, measles is seldom a dangerous infection and prophylaxis by mass vaccination is hardly justifiable.
General Measures.—Contacts who have not previously suffered from measles are usually excluded from school for three weeks from the date of onset of the last case in the house. No restrictions need be applied to children who have previously suffered from measles. When measles is prevalent, susceptible children should not attend parties, the cinema or other gatherings. The prevention of exposure of children under eighteen months of age should be particularly impressed.
Curative Treatment.—General Management.—Isolation of the child at home is desirable although in the usual circumstances by the time the diagnosis is made the other children will generally have been infected. Since the main danger arises from secondary bacterial infection isolation will reduce the chances of such infection from without. The nursing of the child calls for no special measures apart from attention to the eyes, nose and mouth. In the early stages photophobia is often troublesome and makes screening of strong light desirable. When there is much conjunctivitis and blepharitis gentle cleansing with weak boric solution is useful and, after cleansing, the lids should be smeared with petroleum jelly to prevent sticking. The conjunctivitis usually clears in two to three days and if it persists the possibility of corneal ulceration should be considered. So far as the nose and mouth are concerned all that is required is frequent and gentle cleansing.
Tracheitis and laryngitis usually resolve quickly without treatment. In the young child or the adult they may give rise to more difficulty—in the former from partial obstruction of the airway and in the latter because of the substernal pain from coughing. Inhalation of steam with Friar's balsam is usually effective in relieving the child although occasionally tracheostomy is required. In the adult syrup of codeine phosphate or the elixir of methadone should be prescribed.
Prophylactic Chemotherapy.—Antibiotics have no therapeutic effect upon the virus stage of the infection. The patient is at risk only from secondary bacterial complications during the time that mucosal damage is being produced by virus. Once this period is past, convalescence is usually straightforward. Although the administration of antibiotics prophylactically as a routine during the early catarrhal stage seems desirable it is not recommended. With the form of measles now prevalent complications occur in a small proportion of cases and should be treated as they arise. Benzylpenicillin is effective in most cases as the commonest pathogens are Str. pyogenes and pneumococcus.
Complications.—Bronchopneumonia.—Bronchopneumonia is the most serious complication. Benzylpenicillin, given intramuscularly, should be the antibiotic of first choice and, when this treatment proves effective, it is often possible to change to oral preparations (p. 60).A mild degree of laryngitis is a common early symptom in measles. As a general rule laryngitis during the catarrhal stage is of virus origin and improves as the rash appears. When laryngitis arises after the appearance of the rash the possibility of diphtheritic infection should be kept in mind. If the child has not been immunized, a dose of 4,000 units of diphtheria antitoxin is desirable. Further treatment should be on the lines detailed on p. 671.
In the same way, gastroenteritis may be expected during the catarrhal or early rash stage as a natural part of the disease ; its occurrence, thereafter, should raise the immediate suspicion of dysentery. The possibility of acute appendicitis should not be forgotten.
Infection of the middle ear cleft is perhaps the most important complication as its careless management may leave the child with a chronic suppurative otitis media. Thus examination of the drumheads is an important part of the final clinical examination. Bacteriological examination of any aural discharge is essential so that an appropriate antibiotic—given systemically—may be chosen.
Acute encephalitis can occur with this as with other virus infections. Although a severe infection is not common, recent studies have indicated that mild encephalitis occurs much more frequently than was previously suspected. Indeed the remote possibility of encephalitis is one of the reasons for caution in the use of live measles virus vaccine. •
Convalescence.—In an uncomplicated case the child may be allowed out of bed about the fifth to seventh day from the onset of the disease, and out of isolation on the tenth day.
MENINGOCOCCAL INFECTIONS1
It is now clear that acute meningeal involvement must be regarded as only one form of meningococcal infection. Two other syndromes—acute fulminating septicaemia often with adrenal haemorrhage and chronic septicaemia usually unaccompanied by meningitis—are likely to be seen during epidemic periods ; indeed, the practitioner should have them especially in mind during the first and last two months of the year when the annual prevalence is at its height. For the recognition of both, the first essential is that the clinician remembers the possibility of their occurrence ; the features are sufficiently definite to permit a clinical diagnosis with a fair degree of accuracy. Although uncommon, attention is drawn to their existence, for in one—chronic septicaemia—correct treatment achieves rapid cure and may, in some cases, prevent subsequent meningitis ; while, in the other, only the most rapid diagnosis and immediate institution of proper measures hold out any possibility of recovery. The whole course from onset to death of a case of acute septicaemia with suprarenal haemorrhage may take but a few hours. In many fulminant cases of meningitis, too, the extensive nature of the skin haemorrhages suggests the possibility of suprarenal damage ; these cases should receive the appropriate treatment about to be described.
Such a concept of meningococcal infection is important because it draws attention to the mode of access of the meningococcus to the meninges. This route is—nasopharynx, blood stream, choroid plexus, meninges. Every case of meningococcal meningitis should be regarded as blood-borne. Treatment must thus be aimed not solely at the meninges but also at a systemic infection.1 All manifestations of infection by the meningococcus in Great Britain are notifiable under the general title " meningococcal infections It is perhaps because the sulphonamides can follow so closely the route of the meningococcus that they have proved more efficacious than penicillin.
Meningococcal infections are notifiable. The incubation period is from three to seven days.
Prevention and Epidemiological Control.—Carriers play an important part in the spread of the disease, and because of this it used to be regarded as valuable to search for carriers on the occurrence of a case. It is now appreciated that a simple routine examination of the nasopharynx on a single occasion may well fail to isolate the organism, although repeated examinations will often succeed. Indeed, in some carefully conducted studies it has been shown that practically all of the contacts were carrying the organism. This is especially the case in closed or semi-closed communities. Search for carriers has, therefore, been abandoned as a method of control. Fortunately, in the general population, case-to-case infection is not common and it is unusual to get more than one case in a household. In dormitories or army barracks the living—and particularly the recreational—accommodation should be reviewed. Measures for the control of dust such as wet-sweeping or oiling of floors are useful. It is probably true to say that the danger of overcrowded sleeping quarters and lecture halls is due as much to the periodic disturbance of dust by movement as to the actual close proximity of the inhabitants. Good ventilation is thus of great importance. It is possible that minor upper respiratory tract infections assist in the spread of meningococci, and in army camps, after a case has occurred, patients suffering from such complaints should be closely examined—especially if there is fever or a complaint of headache.
The administration of sulphonamides to contacts has a limited place when infection arises in a closed community. When this form of prophylaxis is used the doctor should be on the look-out for the re-appearance of organisms when treatment is stopped, for meningococci can develop sulphonamide resistance. Indeed penicillin-resistant strains are also encountered and, although they are uncommon, it should become increasingly the practice to test all meningococci isolated for their sensitivity to the common antibiotics.
Where the disease is epidemic in a community, it is well to remember that the highest attack rate is upon the child population under five years. The practitioner should take every opportunity to reinforce the advice given at these times by the Medical Officer of Health through the press. Crowded places should be avoided ; and the danger of sleeping in "overcrowded and badly ventilated rooms must be emphasized.
In certain areas the first case of measles occurring in a household has to be notified to the Medical Officer of Health. Otherwise the disease is not notifiable. The incubation period is usually from nine to eleven days, but may vary from seven to fourteen days.
Preventive Treatment.—Passive Immunization.—An attack of measles can be prevented or modified by the intramuscular injection of an appropriate dose of gamma-globulin in the early stages of incubation. The dose of gamma-globulin cannot be stated with the accuracy associated with most biological products because the content of antibody is variable and there are minor variations in its preparation. For the child between one and three years of age the dose should be from 0-25 to 0-75 g. When given during the first few days of the incubation period such a dose will usually give complete protection, but when this is not attained, at least the subsequent attack is reduced in severity. The use of gamma-globulin should be restricted to contacts under the age of 18 months or children who are seriously debilitated, for example, after recovery from whooping-cough or pneumonia.
Active Immunisation.—Both a killed and a live attenuated virus vaccine are now available. The immunity obtained by the killed vaccine is of relatively short duration and a proportion of those inoculated with it acquire the disease at a subsequent exposure. The live attenuated virus vaccine produces a satisfactory immunity which certainly lasts for some years. The vaccine is freeze-dried and reconstituted with ro ml. of sterile distilled water before use. The injection is given subcutaneously. A proportion of the children inoculated (from 15-25 per cent.) develop moderately severe febrile reactions about a week after injection, while a few show evidence of a mild attack of measles. These reactions have been mitigated (a) by the simultaneous injection of gamma globulin and (&) by preliminary vaccination with the killed vaccine.
At present these vaccines are used mainly in those countries where the mortality from measles is high. In other communities where there are adequate standards of child health and where malnutrition is rare, measles is seldom a dangerous infection and prophylaxis by mass vaccination is hardly justifiable.
General Measures.—Contacts who have not previously suffered from measles are usually excluded from school for three weeks from the date of onset of the last case in the house. No restrictions need be applied to children who have previously suffered from measles. When measles is prevalent, susceptible children should not attend parties, the cinema or other gatherings. The prevention of exposure of children under eighteen months of age should be particularly impressed.
Curative Treatment.—General Management.—Isolation of the child at home is desirable although in the usual circumstances by the time the diagnosis is made the other children will generally have been infected. Since the main danger arises from secondary bacterial infection isolation will reduce the chances of such infection from without. The nursing of the child calls for no special measures apart from attention to the eyes, nose and mouth. In the early stages photophobia is often troublesome and makes screening of strong light desirable. When there is much conjunctivitis and blepharitis gentle cleansing with weak boric solution is useful and, after cleansing, the lids should be smeared with petroleum jelly to prevent sticking. The conjunctivitis usually clears in two to three days and if it persists the possibility of corneal ulceration should be considered. So far as the nose and mouth are concerned all that is required is frequent and gentle cleansing.
Tracheitis and laryngitis usually resolve quickly without treatment. In the young child or the adult they may give rise to more difficulty—in the former from partial obstruction of the airway and in the latter because of the substernal pain from coughing. Inhalation of steam with Friar's balsam is usually effective in relieving the child although occasionally tracheostomy is required. In the adult syrup of codeine phosphate or the elixir of methadone should be prescribed.
Prophylactic Chemotherapy.—Antibiotics have no therapeutic effect upon the virus stage of the infection. The patient is at risk only from secondary bacterial complications during the time that mucosal damage is being produced by virus. Once this period is past, convalescence is usually straightforward. Although the administration of antibiotics prophylactically as a routine during the early catarrhal stage seems desirable it is not recommended. With the form of measles now prevalent complications occur in a small proportion of cases and should be treated as they arise. Benzylpenicillin is effective in most cases as the commonest pathogens are Str. pyogenes and pneumococcus.
Complications.—Bronchopneumonia.—Bronchopneumonia is the most serious complication. Benzylpenicillin, given intramuscularly, should be the antibiotic of first choice and, when this treatment proves effective, it is often possible to change to oral preparations (p. 60).A mild degree of laryngitis is a common early symptom in measles. As a general rule laryngitis during the catarrhal stage is of virus origin and improves as the rash appears. When laryngitis arises after the appearance of the rash the possibility of diphtheritic infection should be kept in mind. If the child has not been immunized, a dose of 4,000 units of diphtheria antitoxin is desirable. Further treatment should be on the lines detailed on p. 671.
In the same way, gastroenteritis may be expected during the catarrhal or early rash stage as a natural part of the disease ; its occurrence, thereafter, should raise the immediate suspicion of dysentery. The possibility of acute appendicitis should not be forgotten.
Infection of the middle ear cleft is perhaps the most important complication as its careless management may leave the child with a chronic suppurative otitis media. Thus examination of the drumheads is an important part of the final clinical examination. Bacteriological examination of any aural discharge is essential so that an appropriate antibiotic—given systemically—may be chosen.
Acute encephalitis can occur with this as with other virus infections. Although a severe infection is not common, recent studies have indicated that mild encephalitis occurs much more frequently than was previously suspected. Indeed the remote possibility of encephalitis is one of the reasons for caution in the use of live measles virus vaccine. •
Convalescence.—In an uncomplicated case the child may be allowed out of bed about the fifth to seventh day from the onset of the disease, and out of isolation on the tenth day.
MENINGOCOCCAL INFECTIONS1
It is now clear that acute meningeal involvement must be regarded as only one form of meningococcal infection. Two other syndromes—acute fulminating septicaemia often with adrenal haemorrhage and chronic septicaemia usually unaccompanied by meningitis—are likely to be seen during epidemic periods ; indeed, the practitioner should have them especially in mind during the first and last two months of the year when the annual prevalence is at its height. For the recognition of both, the first essential is that the clinician remembers the possibility of their occurrence ; the features are sufficiently definite to permit a clinical diagnosis with a fair degree of accuracy. Although uncommon, attention is drawn to their existence, for in one—chronic septicaemia—correct treatment achieves rapid cure and may, in some cases, prevent subsequent meningitis ; while, in the other, only the most rapid diagnosis and immediate institution of proper measures hold out any possibility of recovery. The whole course from onset to death of a case of acute septicaemia with suprarenal haemorrhage may take but a few hours. In many fulminant cases of meningitis, too, the extensive nature of the skin haemorrhages suggests the possibility of suprarenal damage ; these cases should receive the appropriate treatment about to be described.
Such a concept of meningococcal infection is important because it draws attention to the mode of access of the meningococcus to the meninges. This route is—nasopharynx, blood stream, choroid plexus, meninges. Every case of meningococcal meningitis should be regarded as blood-borne. Treatment must thus be aimed not solely at the meninges but also at a systemic infection.1 All manifestations of infection by the meningococcus in Great Britain are notifiable under the general title " meningococcal infections It is perhaps because the sulphonamides can follow so closely the route of the meningococcus that they have proved more efficacious than penicillin.
Meningococcal infections are notifiable. The incubation period is from three to seven days.
Prevention and Epidemiological Control.—Carriers play an important part in the spread of the disease, and because of this it used to be regarded as valuable to search for carriers on the occurrence of a case. It is now appreciated that a simple routine examination of the nasopharynx on a single occasion may well fail to isolate the organism, although repeated examinations will often succeed. Indeed, in some carefully conducted studies it has been shown that practically all of the contacts were carrying the organism. This is especially the case in closed or semi-closed communities. Search for carriers has, therefore, been abandoned as a method of control. Fortunately, in the general population, case-to-case infection is not common and it is unusual to get more than one case in a household. In dormitories or army barracks the living—and particularly the recreational—accommodation should be reviewed. Measures for the control of dust such as wet-sweeping or oiling of floors are useful. It is probably true to say that the danger of overcrowded sleeping quarters and lecture halls is due as much to the periodic disturbance of dust by movement as to the actual close proximity of the inhabitants. Good ventilation is thus of great importance. It is possible that minor upper respiratory tract infections assist in the spread of meningococci, and in army camps, after a case has occurred, patients suffering from such complaints should be closely examined—especially if there is fever or a complaint of headache.
The administration of sulphonamides to contacts has a limited place when infection arises in a closed community. When this form of prophylaxis is used the doctor should be on the look-out for the re-appearance of organisms when treatment is stopped, for meningococci can develop sulphonamide resistance. Indeed penicillin-resistant strains are also encountered and, although they are uncommon, it should become increasingly the practice to test all meningococci isolated for their sensitivity to the common antibiotics.
Where the disease is epidemic in a community, it is well to remember that the highest attack rate is upon the child population under five years. The practitioner should take every opportunity to reinforce the advice given at these times by the Medical Officer of Health through the press. Crowded places should be avoided ; and the danger of sleeping in "overcrowded and badly ventilated rooms must be emphasized.
INFLUENZA AND VIRUS INFECTIONS OF THE RESPIRATORY TRACT
Although it is impossible to compute their total frequency, virus infections of the respiratory tract are certainly the commonest cause of illness in Britain. The rise in the notifications of pneumonia during winter, the new claims for sickness benefit under health insurance and the deaths in persons over the age of 65 years reflect the frequency of such infections. The appearance of a more virulent virus such as influenza A swell the figures ; but it is certain that in every winter a number of different viruses play a part in the seasonal epidemic.
People in all age-groups are susceptible to infection, but for those at the extremes of life the illness is particularly hazardous. Respiratory virus infection is not only more common in children under the age of five years but, in the first year of life, the illness is more severe. Indeed, simple involvement of the upper respiratory tract without evidence of pneumonia—what would in the adult be merely a " cold "—can produce in the infant a life-threatening illness. Again, in the elderly, degenerative processes, especially of the heart or lungs, make pneumonia a more frequent and serious complication, and the same can be said for patients at all ages suffering from chronic cardiac disease or chronic bronchitis. It is probable that the majority of the common respiratory viruses reach the mucosa directly from the inspired air. This has two consequences. Firstly, since cellular invasion is direct the presence of humoral antibody is relatively unimportant, at least so far as the initiation of infection is concerned. This may in part explain why immunity to these common infections seems so poor and susceptibility to re-infection throughout life so common. Secondly, vims multiplication in mucosal cells deranges their metabolism and may ultimately destroy them. The alteration to cellular physiology, however, is non-specific. The response of the cell is limited and this means that the signs and symptoms and their localization in the respiratory tract can be the same for a number of viruses. In other words the same virus may produce a variety of illnesses and a number of viruses may produce the same type of illness. This makes a very confusing picture for the clinician, especially as the number of viruses known to produce respiratory infection is continually increasing. The following table lists some of the more important of these viruses but it must be appreciated that each family contains a number of different sere-types.
Precise determination of the responsible virus on the strength of clinical signs and symptoms is thus impossible. Detailed virological examination is required and such methods cannot be applied in every case.
Several factors determine the severity of the illness. The importance of certain host factors has already been mentioned. There is no doubt about the severity of influenza virus infections and this is especially apparent when new antigenic variants of the A type arise as they did for example in 1918 and 1957. Apart, however, from any innate virulence it would seem likely that severity is a measure of the rapidity with which virus can infect large numbers of mucosal cells. Pneumonia may thus occur purely as a result of rapid dissemination of virus throughout the respiratory tract. But in the majority of cases, the appearance of complications can usually be explained by a superimposed bacterial infection. The pathogens involved are those which are present in the naso-pharynx. The pneumococcus is the organism most commonly isolated, but in
children, H. influenza and in adults Staph. aureus should be thought of for these produce the most severe illnesses.
Antibiotics have no value in the treatment of the uncomplicated virus infections. Unless there is evidence of pneumonia or other indication of bacterial infection they should not be used. The importance of bacteriological examination in such cases is stressed, for the micro-organism may prove to be resistant to the normal antibiotic of first choice, namely, penicillin.
The incubation period of most of these infections is short—one to two days. Influenza is only notifiable when it is complicated by pneumonia.
Prevention and Epidemiological Control.—There is no method whereby the spread of infection can be prevented. Free ventilation and avoidance of crowds are clearly advisable, but since many people suffering from minor degrees of illness continue with their daily work, the prevalent virus is constantly present in crowded trains and buses, so that the avoidance of contact is virtually impossible.
Killed virus vaccines have a limited place in active immunization against influenza. A major difficulty lies in the fact that the various strains of influenza virus behave differently as antigens. Thus vaccines to be effective must be prepared from strains which are producing the current infections. As the Asian strain of 1957 is still the prevalent virus there is some justification for immunizing selected groups in the population if they are at special risk (e.g. doctors, nurses and the staffs of certain public services) or because of their known susceptibility to severe infection (e.g. persons with chronic pulmonary or cardiac disease). For adults a single dose of ro ml. subcutaneously in October or November is recommended since adults may be assumed to have had some past experience of the virus antigens and the injection has thus a " booster " effect. Virus vaccines prepared from adenovirus strains have been used experimentally but their use in the general population is not recommended.
Curative Treatment.—General Management.—Ideally any person with a febrile upper respiratory tract infection should be isolated from the community in bed until the temperature has returned to normal. Unfortunately, mankind is not so tractable, and the ability to " carry on " is regarded as a virtue. There is no specific serum or drug treatment of proven value, so that the mainstay is efficient nursing and treatment of symptoms (p. i). The nursing procedures that require emphasis are the hygiene of the mouth, nose, eyes and skin. For the relief of pain, aspirin and Dover's powder will usually suffice ;
when there is complaint of sore throat, the aspirin should be slowly dissolved in the saliva and gradually swallowed, when it often has a local analgesic effect. Troublesome cough is best relieved by the administration of a sedative such as syrup codeine phosphate. Cyanosis is usually a sign of pneumonia and an indication for oxygen (p. 929).
Antibiotics.—The response of post-influenzal pneumonia to chemotherapy is often unsatisfactory. At least part of the explanation for this is that in severe infections there is extensive damage to the mucosa of the upper respiratory tract and bacterial superinfection is correspondingly great. Two pathogens which have already been mentioned—H. infiuenssce and Staph. aureus—are particularly dangerous secondary invaders and their prompt detection warrants bacteriological examination of the sputum from patients with pneumonia during influenza virus epidemics. Tetracycline (2-0 g. during the first 12 hours) is advised as the antibiotic of first choice while bacteriological results are awaited. In the fulminating cases two dangers must be emphasized. In some cases the hasmor-rhagic pulmonary secretion is so profuse that the patient cannot rid himself of it quickly enough and is in danger of suffocation. In others the extensive ulceration of trachea and bronchi results in desiccation with extensive crusting. These patients can be successfully managed by tracheostomy, removal of secretions by suction, nursing in a highly humid atmosphere or even by the use of a mechanical respirator.
Other Complications.—Pyogenic complications may arise in the para-nasal sinuses or middle ear. In this event there is less urgency in beginning treatment, and a bacteriological examination which includes sensitivity testing of any pathogens isolated should precede the onset of treatment. The antibiotic to be used may then be chosen with some precision. Toxic myocarditis must always be borne in mind, especially in the older patient.
Convalescence.—The importance of an adequate period of convalescence after influenza must be impressed particularly upon the older patient. Owing to the toxic effect of influenza on the myocardium it is wise even in the mildest case to advise rest in bed for at least three days after the temperature has settled. This applies particularly to those over the age of 35 years. In more severe attacks this period should be extended to one to two weeks. The response of the heart to increased exertion must be carefully watched, and a further rest enforced if this be unsatisfactory. Cough due to tracheitis is sometimes very persistent, but is usually relieved to some extent by the administration of a teaspoonful thrice daily of either elixir of methadone or syrup of codeine phosphate. Infected nasal sinuses may be the exciting factor and should receive' appropriate treatment.
People in all age-groups are susceptible to infection, but for those at the extremes of life the illness is particularly hazardous. Respiratory virus infection is not only more common in children under the age of five years but, in the first year of life, the illness is more severe. Indeed, simple involvement of the upper respiratory tract without evidence of pneumonia—what would in the adult be merely a " cold "—can produce in the infant a life-threatening illness. Again, in the elderly, degenerative processes, especially of the heart or lungs, make pneumonia a more frequent and serious complication, and the same can be said for patients at all ages suffering from chronic cardiac disease or chronic bronchitis. It is probable that the majority of the common respiratory viruses reach the mucosa directly from the inspired air. This has two consequences. Firstly, since cellular invasion is direct the presence of humoral antibody is relatively unimportant, at least so far as the initiation of infection is concerned. This may in part explain why immunity to these common infections seems so poor and susceptibility to re-infection throughout life so common. Secondly, vims multiplication in mucosal cells deranges their metabolism and may ultimately destroy them. The alteration to cellular physiology, however, is non-specific. The response of the cell is limited and this means that the signs and symptoms and their localization in the respiratory tract can be the same for a number of viruses. In other words the same virus may produce a variety of illnesses and a number of viruses may produce the same type of illness. This makes a very confusing picture for the clinician, especially as the number of viruses known to produce respiratory infection is continually increasing. The following table lists some of the more important of these viruses but it must be appreciated that each family contains a number of different sere-types.
Precise determination of the responsible virus on the strength of clinical signs and symptoms is thus impossible. Detailed virological examination is required and such methods cannot be applied in every case.
Several factors determine the severity of the illness. The importance of certain host factors has already been mentioned. There is no doubt about the severity of influenza virus infections and this is especially apparent when new antigenic variants of the A type arise as they did for example in 1918 and 1957. Apart, however, from any innate virulence it would seem likely that severity is a measure of the rapidity with which virus can infect large numbers of mucosal cells. Pneumonia may thus occur purely as a result of rapid dissemination of virus throughout the respiratory tract. But in the majority of cases, the appearance of complications can usually be explained by a superimposed bacterial infection. The pathogens involved are those which are present in the naso-pharynx. The pneumococcus is the organism most commonly isolated, but in
children, H. influenza and in adults Staph. aureus should be thought of for these produce the most severe illnesses.
Antibiotics have no value in the treatment of the uncomplicated virus infections. Unless there is evidence of pneumonia or other indication of bacterial infection they should not be used. The importance of bacteriological examination in such cases is stressed, for the micro-organism may prove to be resistant to the normal antibiotic of first choice, namely, penicillin.
The incubation period of most of these infections is short—one to two days. Influenza is only notifiable when it is complicated by pneumonia.
Prevention and Epidemiological Control.—There is no method whereby the spread of infection can be prevented. Free ventilation and avoidance of crowds are clearly advisable, but since many people suffering from minor degrees of illness continue with their daily work, the prevalent virus is constantly present in crowded trains and buses, so that the avoidance of contact is virtually impossible.
Killed virus vaccines have a limited place in active immunization against influenza. A major difficulty lies in the fact that the various strains of influenza virus behave differently as antigens. Thus vaccines to be effective must be prepared from strains which are producing the current infections. As the Asian strain of 1957 is still the prevalent virus there is some justification for immunizing selected groups in the population if they are at special risk (e.g. doctors, nurses and the staffs of certain public services) or because of their known susceptibility to severe infection (e.g. persons with chronic pulmonary or cardiac disease). For adults a single dose of ro ml. subcutaneously in October or November is recommended since adults may be assumed to have had some past experience of the virus antigens and the injection has thus a " booster " effect. Virus vaccines prepared from adenovirus strains have been used experimentally but their use in the general population is not recommended.
Curative Treatment.—General Management.—Ideally any person with a febrile upper respiratory tract infection should be isolated from the community in bed until the temperature has returned to normal. Unfortunately, mankind is not so tractable, and the ability to " carry on " is regarded as a virtue. There is no specific serum or drug treatment of proven value, so that the mainstay is efficient nursing and treatment of symptoms (p. i). The nursing procedures that require emphasis are the hygiene of the mouth, nose, eyes and skin. For the relief of pain, aspirin and Dover's powder will usually suffice ;
when there is complaint of sore throat, the aspirin should be slowly dissolved in the saliva and gradually swallowed, when it often has a local analgesic effect. Troublesome cough is best relieved by the administration of a sedative such as syrup codeine phosphate. Cyanosis is usually a sign of pneumonia and an indication for oxygen (p. 929).
Antibiotics.—The response of post-influenzal pneumonia to chemotherapy is often unsatisfactory. At least part of the explanation for this is that in severe infections there is extensive damage to the mucosa of the upper respiratory tract and bacterial superinfection is correspondingly great. Two pathogens which have already been mentioned—H. infiuenssce and Staph. aureus—are particularly dangerous secondary invaders and their prompt detection warrants bacteriological examination of the sputum from patients with pneumonia during influenza virus epidemics. Tetracycline (2-0 g. during the first 12 hours) is advised as the antibiotic of first choice while bacteriological results are awaited. In the fulminating cases two dangers must be emphasized. In some cases the hasmor-rhagic pulmonary secretion is so profuse that the patient cannot rid himself of it quickly enough and is in danger of suffocation. In others the extensive ulceration of trachea and bronchi results in desiccation with extensive crusting. These patients can be successfully managed by tracheostomy, removal of secretions by suction, nursing in a highly humid atmosphere or even by the use of a mechanical respirator.
Other Complications.—Pyogenic complications may arise in the para-nasal sinuses or middle ear. In this event there is less urgency in beginning treatment, and a bacteriological examination which includes sensitivity testing of any pathogens isolated should precede the onset of treatment. The antibiotic to be used may then be chosen with some precision. Toxic myocarditis must always be borne in mind, especially in the older patient.
Convalescence.—The importance of an adequate period of convalescence after influenza must be impressed particularly upon the older patient. Owing to the toxic effect of influenza on the myocardium it is wise even in the mildest case to advise rest in bed for at least three days after the temperature has settled. This applies particularly to those over the age of 35 years. In more severe attacks this period should be extended to one to two weeks. The response of the heart to increased exertion must be carefully watched, and a further rest enforced if this be unsatisfactory. Cough due to tracheitis is sometimes very persistent, but is usually relieved to some extent by the administration of a teaspoonful thrice daily of either elixir of methadone or syrup of codeine phosphate. Infected nasal sinuses may be the exciting factor and should receive' appropriate treatment.
ENCEPHALITIS LETHARGICA {Epidemic Encephalitis)
ERYSIPELAS
Erysipelas is a notifiable disease which should, as a general rule, be treated at home. The incubation period is from three to five days.
Curative Treatment.—Sulphonamides.—The use of the sulphonamide group of drugs has so greatly hastened recovery that no other form of treatment is usually required. Any sulphonamide will prove effective. For an adult, 5 g. daily should be administered for a period of seven days; under the age of five years a daily dose of 3 g. will be found satisfactory.
Penicillin.—Penicillin also achieves rapid cure in erysipelas, but in view of the excellent results obtained with the sulphonamides and the ease of their administration, it is not the treatment of first choice. Exceptions to this general rule are : erysipelas of the leg, in which there is a tendency for invasion of the cellular space with abscess formation ; lesions associated with massive oedema ;when the patient is under two years of age ; and if attacks recur. In such cases the intramuscular injection of 500,000 units of benzylpenicillin twice a day for a period of five days will give more satisfactory results.
Complications.—The incidence of complications is exceedingly low if treatment is begun early. Inflammation of the associated lymph glands is frequently present, but will usually subside without any local treatment. Subcutaneous abscesses (especially of the eyelids) are not infrequent, and incision should be delayed until the activity of the erysipelatous plaque has subsided.
GLANDULAR FEVER
(Infections Mononnckosis)
Epidemics of this acute infectious disease of virus aetiology occur in schools and institutions, and sporadic cases are common among the general population
Although susceptibility to the disease appears to be almost universal, the degree of infectivity is not high. For example, cases of glandular fever can be treated in a mixed ward with no ill results. Fever accompanied by acute enlargement of the lymph glands, particularly of the neck, is the form of the disease commonly met with in children. Febrile and anginose types occur in young adults. A mononuclear leucocytosis is characteristic of the disease. The Paul-Bunnell sheep-cell agglutination test has proved a valuable aid to diagnosis ; agglutination in a titre of i : 160 or higher may be regarded as diagnostic. Unfortunately, the test is often negative in cases which otherwise seem typical. The bacteriologist should be informed if horse serum has been administered, since this causes false positive results.
Glandular fever is not a notifiable disease. The incubation period is usuaUy between five and fifteen days.
Preventive Treatment.—There is no specific method of prophylaxis against glandular fever.
Curative Treatment.—There is no specific treatment: management of the disease is on symptomatic lines. The antibiotics have some value in the anginose forms of infection because of their effect upon the secondarily infecting organisms. A period of three to four days' treatment will usually suffice.
General Management.—The patient should be confined to bed until the temperature has been normal for one week and the glandular swelling markedly diminished. The febrile type with high and prolonged pyrexia lasting several weeks requires to be treated on the same lines as a case of enteric fever.
Meningitis, epistaxis, hsematuria and conjunctivitis are rare complications.
Convalescence.—Recrudescences are liable to occur. Even after mild attacks anaemia and slight debility often persist for several months and the patient should return gradually to normal life. When convalescence is unduly prolonged, careful hasmatological examination is desirable, for some cases of reticulosis have an onset similar to infectious mononucleosis.
THE ENTERIC FEVERS (Typhoid and Paratyphoid Fevers)
The annual occurrence in Britain of one or more outbreaks of enteric fever and the recent one in Aberdeen indicates that, in spite of sanitary precautions,
the risk of contamination of water and food supplies with the enteric group of organisms still persists. S. typhi and S. paratyphi B, the organisms commonly met with in the British Isles, are excreted in the stools and urine during the course of the illness. The unsuspected ambulant case, the missed case, the temporary carrier and the chronic carrier play a very important part in the dissemination of enteric fever. It is probable that even with efficient chemotherapy from 2 to 5 per cent. of all cases of typhoid fever become permanent carriers. That the incidence of the chronic carrier state is higher in women than in men is unfortunate when we consider the possibilities of contamination of food in course of preparation. Although the fascal carrier is more commonly encountered, the urinary carrier is potentially more dangerous. The organisms are discharged intermittently in both stools and urine, so that repeated bacteriological examinations are essential before the carrier state can be excluded.
Although isolation of the pathogen from fascal and urinary specimens is the only exact method of diagnosing carriers, preliminary examination of the blood serum may serve as a useful " screening " test for carriers of S. typhi when large numbers of suspects have to be reviewed. Antibodies for the Vi antigen are almost always to be found in fairly high titre in carriers ; so that if a preliminary blood test is carried out, attention can be directed particularly to those with such antibodies.
Outbreaks, then, are usually a result of the contamination of food or water by a missed case or carrier. Milk or milk products, prepared meats, uncooked vegetables, fruit and shellfish constitute the usual vehicles of infection. A nurse may contract the disease in the course of her duties ; this usually indicates carelessness in the washing of hands. It is important to make a specific prohibition of the eating of any food by the attendant in the ward or room w^ere the disease is being nursed.
Typhoid and paratyphoid fevers are notifiable diseases. The incubation period of typhoid infections is from 12 to 14 days, and of paratyphoid B from 10 to 12 days.
Prevention and Epidemiological Control.—The control of typhoid fever is essentially a problem for the local Public Health Authority and embraces such factors as an efficient system of sewage disposal, a safe water and milk supply, the detection of carriers, the supervision of shellfish, the control of the house-fly and effective supervision of premises where food is sold or prepared.Careful supervision of sewage and water is a commonplace in the large towns, so that widespread epidemics of typhoid are now unusual. In country districts, however, defective cesspools, flooding or ineffective disposal of sewage are still commonly the source of localized outbreaks. Articles of food, especially cold meats and tinned ham and beef have now replaced water as the vehicle of infection, especially of paratyphoid fever, and here the towns are in as much danger as the countryside. Although day-to-day control by Public Health Departments forms an important part of the protection of the public, the early diagnosis of the infected case by the practitioner is of prime importance both in stemming an incipient epidemic and in stopping it once it has started. The value of early blood culture in cases of continued fever must here be emphasized; and the golden rule is to carry out a blood culture on any case which has an unexplained pyrexia for more than three days. A specimen of blood for agglutination tests should be submitted at the same time. The impression that it is only worth while to examine for agglutinins after the end of the first week of illness is quite erroneous. An early specimen may show their presence in low titre, and if a further examination in three or four days shows a rise in titre the diagnosis is almost certain. Of course, previous inoculation against typhoid or paratyphoid to a large extent invalidates the Widal test and no reliance can be placed on the results of a single examination in such persons.
The subdivision of the typhoid group by specific bacteriophages into a number of " phage " types has been of great assistance in tracing the exact source of the epidemic. This has led to greater precision in attributing cases to a particular carrier. Typing may also be of value in indicating the place from which infection has come. In this respect it should be appreciated that the popularity of holidays abroad often introduces a type of organism not indigenous to the country in which the patient takes ill.
Where a number of cases occurs in a district, the practitioner will usually be informed by the local Medical Officer of Health, and co-operation with him in attempts to investigate the source of the epidemic will be of the greatest benefit. The practitioner is in a favourable situation for seeing formes frustes examples of infection and he should bear in mind the fact that many of the illnesses, especially of paratyphoid fever, are mild; diarrhoea may never occur and many cases masquerade as influenza, tonsillitis or bronchitis. In his daily practice, too, he should insist on the boiling of water and milk and in the avoidance of all foods eaten in a raw or partially cooked state. A campaign against flies should be instituted, and here the use of gammexane sprays and dicophane (DDT) play an important part.
Immunisation.—TAB vaccine (either phenolized or acetone-treated) usually contains in each ml. 1,000 millions of S. typhi and 500 millions each of S. paratyphi A and B. Cholera is often included in the vaccine (TABC) and this is a convenient way to immunise persons travelling to the East. The initial dose in adults is 0-5 ml. followed seven to ten days later by i ml.; to children between three and ten years of age 0-25 and 0-5 ml. may be administered. A third injection of i ml. (adult) or 0-5 ml. (child) should be given one week later to persons who are going to live in an endemic area. The injection is given subcutaneously, and as systemic disturbance is liable to follow, any strenuous exertion should be avoided for 24 hours after each dose. Pulmonary tuberculosis, diabetes mellitus and chronic kidney or vascular disease are usually listed as contraindications to inoculation, but when the person is to reside in an endemic area the risks of inoculation are less than the danger of acquiring the disease. The vaccine should not be administered during late pregnancy or during the course of an acute infection. The administration of a more potent vaccine intradermally (0-2 ml.) has been claimed to result in fewer side-effects. Comparative trials have not been reported.
Protection is attained within two weeks of the final injection, and after lasting for some months gradually lessens over a variable period. When a person has to live permanently in an endemic area an occasional booster injection of 0-5 ml. should be given.
Curative Treatment.—Chemotherapy.—Chloramphenicol may now be regarded as a specific form of therapy and should be given to every patient. For the best results early administration is desirable, although success may still be attained when the patient has already been ill for one to two weeks. The dose recommended is i to 2 g. daily for a period of 15 days—the long period being desirable to reduce the tendency to relapse. A high initial dose is unwise, since a " Herxheimer " effect has been noted in some severely ill patients. Treatment with chloramphenicol often produces remarkable improvement within 24 to 48 hours, especially when begun early, but it should be remembered when treatment is started late that in spite of the patient's well-being the ulceration of the bowel and muscular degeneration resulting from toxasmia are still present. It is, therefore, essential to maintain complete bed rest for a period of two to three weeks, until healing of the ulcerated bowel has occurred. Relapse is still a prominent feature of the disease, but fortunately responds to a second course of chloramphenicol. Ampicillin is not recommended for the treatment of the acute infection.
General Management.—The patient must be kept strictly recumbent, but his position should be altered several times daily. Mental rest is essential, and visitors must be excluded. A four-hourly chart must be kept and arrangements made for the prompt notification of serious symptoms to the physician. Stools, urine and other discharges, wash water, soiled linen, nursing utensils, etc., require to be carefully disinfected, and the patient's crockery, cutlery, etc., must be boiled after use. Measures should be taken to rid the sickroom of flies. The nurse must on no account prepare or handle food which is to be consumed by other members of the household.
The mouth and skin require regular and careful cleansing, and precautions have to be taken to prevent the development of pressure sores.
Retention of urine is liable to occur and should receive appropriate treatment. Inspection of the stools, abdomen, lung bases and heart should form part of the physician's daily routine examination.
Diet.—Although treatment with chloramphenicol will often produce rapid amelioration, it must be emphasized that, if bowel ulceration has occurred, time for healing must be allowed. The duration of a strict dietetic regime is now greatly shortened ; but it is essential in the early days of treatment to enforce a low residue diet and to be sure that all evidence of intestinal inflammation has subsided before relaxing these precautions. During the early days of the illness a fluid diet should be administered. The use of a " composite " food such as Complan (Glaxo)—even if only for a part of the diet—makes it easy to ensure that the intake is adequate. Towards the end of the first week, in addition to 2 pints of milk daily, such readily digestible articles as lightly boiled eggs, custard, ice-cream, junket, cream cheese, milk shapes, milk puddings, jellies, mashed potatoes with butter or gravy, prepared breakfast foods, stewed apples, plain chocolate, thin bread and butter, sponge cake, and minced chicken or beef may be included in the diet.
Complications.—As soon as the patient has been effectively brought under chemotherapeutic control, the symptoms and signs which were formerly dreaded—persistent diarrhcea, meteorism and intense toxaemia—either fail to appear or rapidly disappear. Only two points need to be borne in mind; first, ulceration may still be extensive even when the patient seems well so that perforation or hsemorrhage still occasionally occur; second, despite clinical improvement, organisms may persist in the stool so that the patient should not be assumed to be free from infection. Relapse, as has already been indicated, is a common occurrence and may even occur after the 15-day course of treatment.Haemorrhage and Perforation —The practitioner must be on the lookout for these serious complications, especially during the third week of the illness. On the first appearance of blood in the stools or a sudden drop in temperature accompanied by a rising pulse rate, 15 mg. of morphine and 0-6 mg. of atropine sulphate should be injected without delay. Further treatment will depend on the severity or persistence of the hsemorrhage but preparations should be made for blood transfusion.
Surgical assistance must be summoned immediately perforation is suspected. Morphine should be withheld until the diagnosis is confirmed.
Phlebitis.—Thrombosis in the veins of the lower limbs is a common complication during convalescence. The affected limb is immobilized with pillows for two weeks, after which period gentle massage and passive movements may be started. Suitable analgesics will help to relieve the early pain. The use of anticoagulants is contraindicated because of the danger of precipitating haemorrhage from the bowel.
Other Complications.—The pain of cholecystitis can be relieved by the local application of hot fomentations and the hypodermic injection of pethidine or morphine and atropine.
Periosteitis or osteomyelitis must be treated on surgical lines. Material from a periosteal abscess may contain typhoid bacilli, and soiled dressings should be handled with care.
Convalescence.—It is advisable to confine the patient to bed for at least 14 days after the temperature has returned to normal. By this time the danger of relapse is usually past. Six consecutive negative cultures for enteric organisms must be obtained at two- or three-day intervals from stools and urine prior to the release of the patient from isolation. The rapid clinical recovery can encourage the clinician to think that bacteriological clearance is also rapidly achieved. This is not the case; chloramphenicol is not bactericidal and persistent excretion of organisms is common during convalescence. If the patient is involved in the preparation of food, specimens of fasces and urine should be examined six weeks after discharge from hospital and the Public Health Department should maintain an interest in the patient for a year.
Treatment of Carriers.—As was emphasized in the discussion of diphtheria carriers, the carrier state often superimposes itself upon some preexisting chronic condition and this makes the treatment of the established carrier far from satisfactory. Unfortunately many chronic carriers are unaware that they ever suffered from the disease. In the case of a urinary carrier, a full examination of the urinary tract is desirable, for it is sometimes possible to rectify a coexistent abnormality. The faecal carrier state is often associated with chronic cholecystitis and, perhaps for this reason, is commoner in women;modern methods of anaesthesia have so greatly reduced the hazards of surgical interference that cholecystectomy should receive serious consideration in such cases. When the carrier state is found to arise from a chronic bone lesion, appropriate surgical measures are usually successful.
There is still no method which can be guaranteed to eradicate organisms from the chronic carrier. Assessment of cure is made difficult by the fact that excretion of organisms is usually intermittent and, even without treatment, negative results may be obtained over a period of a few months. For this reason at least twelve months of freedom from excretion are essential before a carrier is regarded as cured. Recently, impressive results have been obtained by the oral administration of ampicillin, ro g. six hourly, along with probenecid, ro g. twice a day. The treatment must be continuous and persistent over a period of three months. Short term treatment is valueless. The development of erythe-matous rashes during the preliminary stages of treatment is sometimes seen but may be ignored. The only satisfactory test of cure is the examination of faecal specimens for pathogens and this should continue until negative results have been consistently obtained for one year.
It is impractical to expect the chronic carrier to remain in hospital during this long period of treatment and bacteriological follow-up. He (or more frequently she) may be allowed home under the supervision of the family doctor and the Medical Officer of Health who will be responsible for obtaining further fascal specimens for bacteriological examination. Before dismissal from hospital, the members of the household should be immunized with TAB vaccine.
Finally, it should be emphasized that in Britain, where endogenous enteric is now uncommon, the most rigorous steps should be taken to eliminate the carrier state after an acute attack. A device which has great value in monitoring individual households or the community as a whole is the " sewer-swab ". These can be inserted into the domestic sewer pipe or main sewers and after remaining there for a period of days are submitted to special bacteriological examination. They often disclose unsuspected pathogens.
the risk of contamination of water and food supplies with the enteric group of organisms still persists. S. typhi and S. paratyphi B, the organisms commonly met with in the British Isles, are excreted in the stools and urine during the course of the illness. The unsuspected ambulant case, the missed case, the temporary carrier and the chronic carrier play a very important part in the dissemination of enteric fever. It is probable that even with efficient chemotherapy from 2 to 5 per cent. of all cases of typhoid fever become permanent carriers. That the incidence of the chronic carrier state is higher in women than in men is unfortunate when we consider the possibilities of contamination of food in course of preparation. Although the fascal carrier is more commonly encountered, the urinary carrier is potentially more dangerous. The organisms are discharged intermittently in both stools and urine, so that repeated bacteriological examinations are essential before the carrier state can be excluded.
Although isolation of the pathogen from fascal and urinary specimens is the only exact method of diagnosing carriers, preliminary examination of the blood serum may serve as a useful " screening " test for carriers of S. typhi when large numbers of suspects have to be reviewed. Antibodies for the Vi antigen are almost always to be found in fairly high titre in carriers ; so that if a preliminary blood test is carried out, attention can be directed particularly to those with such antibodies.
Outbreaks, then, are usually a result of the contamination of food or water by a missed case or carrier. Milk or milk products, prepared meats, uncooked vegetables, fruit and shellfish constitute the usual vehicles of infection. A nurse may contract the disease in the course of her duties ; this usually indicates carelessness in the washing of hands. It is important to make a specific prohibition of the eating of any food by the attendant in the ward or room w^ere the disease is being nursed.
Typhoid and paratyphoid fevers are notifiable diseases. The incubation period of typhoid infections is from 12 to 14 days, and of paratyphoid B from 10 to 12 days.
Prevention and Epidemiological Control.—The control of typhoid fever is essentially a problem for the local Public Health Authority and embraces such factors as an efficient system of sewage disposal, a safe water and milk supply, the detection of carriers, the supervision of shellfish, the control of the house-fly and effective supervision of premises where food is sold or prepared.Careful supervision of sewage and water is a commonplace in the large towns, so that widespread epidemics of typhoid are now unusual. In country districts, however, defective cesspools, flooding or ineffective disposal of sewage are still commonly the source of localized outbreaks. Articles of food, especially cold meats and tinned ham and beef have now replaced water as the vehicle of infection, especially of paratyphoid fever, and here the towns are in as much danger as the countryside. Although day-to-day control by Public Health Departments forms an important part of the protection of the public, the early diagnosis of the infected case by the practitioner is of prime importance both in stemming an incipient epidemic and in stopping it once it has started. The value of early blood culture in cases of continued fever must here be emphasized; and the golden rule is to carry out a blood culture on any case which has an unexplained pyrexia for more than three days. A specimen of blood for agglutination tests should be submitted at the same time. The impression that it is only worth while to examine for agglutinins after the end of the first week of illness is quite erroneous. An early specimen may show their presence in low titre, and if a further examination in three or four days shows a rise in titre the diagnosis is almost certain. Of course, previous inoculation against typhoid or paratyphoid to a large extent invalidates the Widal test and no reliance can be placed on the results of a single examination in such persons.
The subdivision of the typhoid group by specific bacteriophages into a number of " phage " types has been of great assistance in tracing the exact source of the epidemic. This has led to greater precision in attributing cases to a particular carrier. Typing may also be of value in indicating the place from which infection has come. In this respect it should be appreciated that the popularity of holidays abroad often introduces a type of organism not indigenous to the country in which the patient takes ill.
Where a number of cases occurs in a district, the practitioner will usually be informed by the local Medical Officer of Health, and co-operation with him in attempts to investigate the source of the epidemic will be of the greatest benefit. The practitioner is in a favourable situation for seeing formes frustes examples of infection and he should bear in mind the fact that many of the illnesses, especially of paratyphoid fever, are mild; diarrhoea may never occur and many cases masquerade as influenza, tonsillitis or bronchitis. In his daily practice, too, he should insist on the boiling of water and milk and in the avoidance of all foods eaten in a raw or partially cooked state. A campaign against flies should be instituted, and here the use of gammexane sprays and dicophane (DDT) play an important part.
Immunisation.—TAB vaccine (either phenolized or acetone-treated) usually contains in each ml. 1,000 millions of S. typhi and 500 millions each of S. paratyphi A and B. Cholera is often included in the vaccine (TABC) and this is a convenient way to immunise persons travelling to the East. The initial dose in adults is 0-5 ml. followed seven to ten days later by i ml.; to children between three and ten years of age 0-25 and 0-5 ml. may be administered. A third injection of i ml. (adult) or 0-5 ml. (child) should be given one week later to persons who are going to live in an endemic area. The injection is given subcutaneously, and as systemic disturbance is liable to follow, any strenuous exertion should be avoided for 24 hours after each dose. Pulmonary tuberculosis, diabetes mellitus and chronic kidney or vascular disease are usually listed as contraindications to inoculation, but when the person is to reside in an endemic area the risks of inoculation are less than the danger of acquiring the disease. The vaccine should not be administered during late pregnancy or during the course of an acute infection. The administration of a more potent vaccine intradermally (0-2 ml.) has been claimed to result in fewer side-effects. Comparative trials have not been reported.
Protection is attained within two weeks of the final injection, and after lasting for some months gradually lessens over a variable period. When a person has to live permanently in an endemic area an occasional booster injection of 0-5 ml. should be given.
Curative Treatment.—Chemotherapy.—Chloramphenicol may now be regarded as a specific form of therapy and should be given to every patient. For the best results early administration is desirable, although success may still be attained when the patient has already been ill for one to two weeks. The dose recommended is i to 2 g. daily for a period of 15 days—the long period being desirable to reduce the tendency to relapse. A high initial dose is unwise, since a " Herxheimer " effect has been noted in some severely ill patients. Treatment with chloramphenicol often produces remarkable improvement within 24 to 48 hours, especially when begun early, but it should be remembered when treatment is started late that in spite of the patient's well-being the ulceration of the bowel and muscular degeneration resulting from toxasmia are still present. It is, therefore, essential to maintain complete bed rest for a period of two to three weeks, until healing of the ulcerated bowel has occurred. Relapse is still a prominent feature of the disease, but fortunately responds to a second course of chloramphenicol. Ampicillin is not recommended for the treatment of the acute infection.
General Management.—The patient must be kept strictly recumbent, but his position should be altered several times daily. Mental rest is essential, and visitors must be excluded. A four-hourly chart must be kept and arrangements made for the prompt notification of serious symptoms to the physician. Stools, urine and other discharges, wash water, soiled linen, nursing utensils, etc., require to be carefully disinfected, and the patient's crockery, cutlery, etc., must be boiled after use. Measures should be taken to rid the sickroom of flies. The nurse must on no account prepare or handle food which is to be consumed by other members of the household.
The mouth and skin require regular and careful cleansing, and precautions have to be taken to prevent the development of pressure sores.
Retention of urine is liable to occur and should receive appropriate treatment. Inspection of the stools, abdomen, lung bases and heart should form part of the physician's daily routine examination.
Diet.—Although treatment with chloramphenicol will often produce rapid amelioration, it must be emphasized that, if bowel ulceration has occurred, time for healing must be allowed. The duration of a strict dietetic regime is now greatly shortened ; but it is essential in the early days of treatment to enforce a low residue diet and to be sure that all evidence of intestinal inflammation has subsided before relaxing these precautions. During the early days of the illness a fluid diet should be administered. The use of a " composite " food such as Complan (Glaxo)—even if only for a part of the diet—makes it easy to ensure that the intake is adequate. Towards the end of the first week, in addition to 2 pints of milk daily, such readily digestible articles as lightly boiled eggs, custard, ice-cream, junket, cream cheese, milk shapes, milk puddings, jellies, mashed potatoes with butter or gravy, prepared breakfast foods, stewed apples, plain chocolate, thin bread and butter, sponge cake, and minced chicken or beef may be included in the diet.
Complications.—As soon as the patient has been effectively brought under chemotherapeutic control, the symptoms and signs which were formerly dreaded—persistent diarrhcea, meteorism and intense toxaemia—either fail to appear or rapidly disappear. Only two points need to be borne in mind; first, ulceration may still be extensive even when the patient seems well so that perforation or hsemorrhage still occasionally occur; second, despite clinical improvement, organisms may persist in the stool so that the patient should not be assumed to be free from infection. Relapse, as has already been indicated, is a common occurrence and may even occur after the 15-day course of treatment.Haemorrhage and Perforation —The practitioner must be on the lookout for these serious complications, especially during the third week of the illness. On the first appearance of blood in the stools or a sudden drop in temperature accompanied by a rising pulse rate, 15 mg. of morphine and 0-6 mg. of atropine sulphate should be injected without delay. Further treatment will depend on the severity or persistence of the hsemorrhage but preparations should be made for blood transfusion.
Surgical assistance must be summoned immediately perforation is suspected. Morphine should be withheld until the diagnosis is confirmed.
Phlebitis.—Thrombosis in the veins of the lower limbs is a common complication during convalescence. The affected limb is immobilized with pillows for two weeks, after which period gentle massage and passive movements may be started. Suitable analgesics will help to relieve the early pain. The use of anticoagulants is contraindicated because of the danger of precipitating haemorrhage from the bowel.
Other Complications.—The pain of cholecystitis can be relieved by the local application of hot fomentations and the hypodermic injection of pethidine or morphine and atropine.
Periosteitis or osteomyelitis must be treated on surgical lines. Material from a periosteal abscess may contain typhoid bacilli, and soiled dressings should be handled with care.
Convalescence.—It is advisable to confine the patient to bed for at least 14 days after the temperature has returned to normal. By this time the danger of relapse is usually past. Six consecutive negative cultures for enteric organisms must be obtained at two- or three-day intervals from stools and urine prior to the release of the patient from isolation. The rapid clinical recovery can encourage the clinician to think that bacteriological clearance is also rapidly achieved. This is not the case; chloramphenicol is not bactericidal and persistent excretion of organisms is common during convalescence. If the patient is involved in the preparation of food, specimens of fasces and urine should be examined six weeks after discharge from hospital and the Public Health Department should maintain an interest in the patient for a year.
Treatment of Carriers.—As was emphasized in the discussion of diphtheria carriers, the carrier state often superimposes itself upon some preexisting chronic condition and this makes the treatment of the established carrier far from satisfactory. Unfortunately many chronic carriers are unaware that they ever suffered from the disease. In the case of a urinary carrier, a full examination of the urinary tract is desirable, for it is sometimes possible to rectify a coexistent abnormality. The faecal carrier state is often associated with chronic cholecystitis and, perhaps for this reason, is commoner in women;modern methods of anaesthesia have so greatly reduced the hazards of surgical interference that cholecystectomy should receive serious consideration in such cases. When the carrier state is found to arise from a chronic bone lesion, appropriate surgical measures are usually successful.
There is still no method which can be guaranteed to eradicate organisms from the chronic carrier. Assessment of cure is made difficult by the fact that excretion of organisms is usually intermittent and, even without treatment, negative results may be obtained over a period of a few months. For this reason at least twelve months of freedom from excretion are essential before a carrier is regarded as cured. Recently, impressive results have been obtained by the oral administration of ampicillin, ro g. six hourly, along with probenecid, ro g. twice a day. The treatment must be continuous and persistent over a period of three months. Short term treatment is valueless. The development of erythe-matous rashes during the preliminary stages of treatment is sometimes seen but may be ignored. The only satisfactory test of cure is the examination of faecal specimens for pathogens and this should continue until negative results have been consistently obtained for one year.
It is impractical to expect the chronic carrier to remain in hospital during this long period of treatment and bacteriological follow-up. He (or more frequently she) may be allowed home under the supervision of the family doctor and the Medical Officer of Health who will be responsible for obtaining further fascal specimens for bacteriological examination. Before dismissal from hospital, the members of the household should be immunized with TAB vaccine.
Finally, it should be emphasized that in Britain, where endogenous enteric is now uncommon, the most rigorous steps should be taken to eliminate the carrier state after an acute attack. A device which has great value in monitoring individual households or the community as a whole is the " sewer-swab ". These can be inserted into the domestic sewer pipe or main sewers and after remaining there for a period of days are submitted to special bacteriological examination. They often disclose unsuspected pathogens.
BACILLARY DYSENTERY TREATMENT
Dysentery must now be regarded as an endemic infection in large cities. In all parts of Great Britain notifications of the disease have increased greatly in recent years, and in view of the mild nature of the symptoms it may be assumed that the notifications represent but a proportion of the actual incidence. It is no longer true to say that the maximal incidence is always in the summer months. Notifications have been excessive throughout the year, and, in some years the peak has occurred in the first quarter. A large proportion of the patients are children under five years of age.. It is not sufficiently well known that the presence of blood or mucus is not a necessary feature of the illness, and in many cases a few loose stools may comprise the whole complaint. As a result, many infections are missed and so increase the spread of the disease. Some convalescents may become carriers for long periods of time and act as a source of infection.
Dysentery is seldom an " individual " infection. When a case is diagnosed in a family it is usual to find some other members with the organism in their stools. Outbreaks in day nurseries and children's homes are commonplace— and here again the diagnosis of one case will often unmask a widespread epidemic of carriers.
Unlike typhoid fever, the infection remains almost entirely localized to the bowel and agglutinins do not appear in the blood to any great degree. Apart from toxic absorption due to bowel ulceration, the main danger in severe infections arises from exhaustion of the patient by loss of fluid and salt in watery stools. Such a degree of severity is fortunately unusual.
Diagnosis depends on accurate bacteriological examination. For this purpose a rectal swab outfit is used since by this means a suitable specimen can be secured quickly and easily. No time should be lost between obtaining the specimen and submitting it to the laboratory. Rectal swabbing and the use of selective media have added great precision to the diagnosis.
Dysentery is a notifiable disease. In Britain Flexner and Sonne types of Sh. dysenteries account for nearly all of the infections. The incubation period is two to five days.Prevention and Epidemiological Control.—The control of ward and institutional outbreaks often presents an overwhelming task. All further admissions should be stopped and a close search made for carriers and missed cases, both among patients and staff. The bacteriologist should be brought into consultation at once, for the addition to his routine work will be considerable and he should therefore be forewarned. Plans should also be prepared for the separation of those found to give positive results and arrangements made for the sterilization of food utensils, bed-pans, etc. Soiled napkins should be dropped direct into covered pails containing lysol. The nursing staff must be instructed regarding the method of transference of the infection and there must be great persistence in a campaign for repeated hand washing and a careful ritual of personal hygiene. The nurses should also be taught that the simplest case of diarrhoea may well be dysentery and that the occurrence of a loose or green stool should be reported at once.
The extent to which bacteriological freedom from infection prior to discharge is enforced must vary from case to case. When the patient is to return to a closed community—service personnel and children from nurseries—and when there is close association with food preparation it is desirable to obtain at least three negative bacteriological reports. When the patient is returning home, however, it is unnecessary to carry out protracted examinations, and the verage case may be regarded as free from infection by the eighth to tenth day of illness.
Curative Treatment.—The majority of cases/due to Sonne and Flexner infections, run a mild course of three or four days and call for little medicinal treatment. The administration of specific serum to cases of Shiga infection is of undoubted value. The dose is up to 100 ml. and the injection should be given intravenously after suitable precautions (p. 50).
SuJphonamides.—In most parts of Great Britain the endemic strains of shigella have now acquired resistance to sulphonamides, which are therefore no longer effective. In areas where this is not the case, sulphadiazine will prove as satisfactory as sulphaguanidine or succinylsulphathiazole.
Antibiotics.—Tetracyclines are effective in securing bacteriological clearance and do so in low dosage. This is undoubtedly important in dealing with food-handlers, etc. They should be used with caution in hospital wards, where the danger of superinfection of the bowel with resistant staphylococci is very real. It is doubtful if this complication will be encountered in general practice. The period of treatment should not exceed five days.
General Management.—The patient must be confined to bed and kept warm from the first symptom of the disease. When the attack is severe the bed-pan should be employed in order to avoid contamination of lavatory seats, etc. When the call to stool is incessant, the bed-pan may be dispensed with and the motions received into tow, which, when soiled, is collected and burnt.
In severe cases it will be necessary to correct the electrolyte disturbance by intravenous infusions. Apart from this, however, there is no need for special dietetic restrictions.
Carriers.—Persistent symptomless carriers are sometimes unmasked in the investigation of an outbreak. The strain isolated should be tested for sensitivity against a wide range of antibiotics effective against gram-negative organisms and an appropriate substance chosen.
Dysentery is seldom an " individual " infection. When a case is diagnosed in a family it is usual to find some other members with the organism in their stools. Outbreaks in day nurseries and children's homes are commonplace— and here again the diagnosis of one case will often unmask a widespread epidemic of carriers.
Unlike typhoid fever, the infection remains almost entirely localized to the bowel and agglutinins do not appear in the blood to any great degree. Apart from toxic absorption due to bowel ulceration, the main danger in severe infections arises from exhaustion of the patient by loss of fluid and salt in watery stools. Such a degree of severity is fortunately unusual.
Diagnosis depends on accurate bacteriological examination. For this purpose a rectal swab outfit is used since by this means a suitable specimen can be secured quickly and easily. No time should be lost between obtaining the specimen and submitting it to the laboratory. Rectal swabbing and the use of selective media have added great precision to the diagnosis.
Dysentery is a notifiable disease. In Britain Flexner and Sonne types of Sh. dysenteries account for nearly all of the infections. The incubation period is two to five days.Prevention and Epidemiological Control.—The control of ward and institutional outbreaks often presents an overwhelming task. All further admissions should be stopped and a close search made for carriers and missed cases, both among patients and staff. The bacteriologist should be brought into consultation at once, for the addition to his routine work will be considerable and he should therefore be forewarned. Plans should also be prepared for the separation of those found to give positive results and arrangements made for the sterilization of food utensils, bed-pans, etc. Soiled napkins should be dropped direct into covered pails containing lysol. The nursing staff must be instructed regarding the method of transference of the infection and there must be great persistence in a campaign for repeated hand washing and a careful ritual of personal hygiene. The nurses should also be taught that the simplest case of diarrhoea may well be dysentery and that the occurrence of a loose or green stool should be reported at once.
The extent to which bacteriological freedom from infection prior to discharge is enforced must vary from case to case. When the patient is to return to a closed community—service personnel and children from nurseries—and when there is close association with food preparation it is desirable to obtain at least three negative bacteriological reports. When the patient is returning home, however, it is unnecessary to carry out protracted examinations, and the verage case may be regarded as free from infection by the eighth to tenth day of illness.
Curative Treatment.—The majority of cases/due to Sonne and Flexner infections, run a mild course of three or four days and call for little medicinal treatment. The administration of specific serum to cases of Shiga infection is of undoubted value. The dose is up to 100 ml. and the injection should be given intravenously after suitable precautions (p. 50).
SuJphonamides.—In most parts of Great Britain the endemic strains of shigella have now acquired resistance to sulphonamides, which are therefore no longer effective. In areas where this is not the case, sulphadiazine will prove as satisfactory as sulphaguanidine or succinylsulphathiazole.
Antibiotics.—Tetracyclines are effective in securing bacteriological clearance and do so in low dosage. This is undoubtedly important in dealing with food-handlers, etc. They should be used with caution in hospital wards, where the danger of superinfection of the bowel with resistant staphylococci is very real. It is doubtful if this complication will be encountered in general practice. The period of treatment should not exceed five days.
General Management.—The patient must be confined to bed and kept warm from the first symptom of the disease. When the attack is severe the bed-pan should be employed in order to avoid contamination of lavatory seats, etc. When the call to stool is incessant, the bed-pan may be dispensed with and the motions received into tow, which, when soiled, is collected and burnt.
In severe cases it will be necessary to correct the electrolyte disturbance by intravenous infusions. Apart from this, however, there is no need for special dietetic restrictions.
Carriers.—Persistent symptomless carriers are sometimes unmasked in the investigation of an outbreak. The strain isolated should be tested for sensitivity against a wide range of antibiotics effective against gram-negative organisms and an appropriate substance chosen.
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