fuvt.| COXSACKIE VIRUS ISOLATED FROM BORNHOLM DISEASE 1856 June 20, 19: finding was that gamma globulin prepared in Fanuary._ 1982, from the pooled plastns of blogs donors the Edinburgh disiricthadl considerable power to protect mice against the views, This activity was a Kast as great SS the capacity of this sample 10 protsct against measles, fand thus there ippeats an sedication that @ comierable Proportion of the duit popetation of Edinburgh fd at Some time been infected with the virus. Unfortunately. no sample of gamma globulin taken before the epidemic war available for comparison, Before any epidemiological significance can be placed on this finding it will therefore Se necessary to eximine a further series ff samples of gamma globulia obtained during non-epidemic Discussion Since neutralizing antibodies appeared in. the serum, reached a titre of 1 in 135. and disappeared after eisht Imonths, it seems justifiable to conclude that both children ‘Sere infected by the virus isolated. “The illnesses experienced by the two children were quite typical of Horaholm disease, being charaeterjzed bythe stklen onset of severe intermittent pain in the upper abdo~ mien, "a short recrudescent course ending in. complete Tecovery, and. no. evidence, radiological or otherwise, of ‘Underlying pulmonary iesion. Occurring as they did Guiring an epidemic, they fulfT all the erteria for the di nosis of ornhoti disease (Seadding, 1951). 'No sign of meningeal involvement was present cither in the two children investigated or ia the 16 other members ff the group. In this there isa resemblance to the to ies described by Metcalfe Brown er al (1952), but it teresting t0 note that, in the epidemic which oseurred at bout the some time at Osford, Davies and Warin (951) Teported a series of 19 cases, 4 of which had definite signs Of meningitis, Bornholm disease may present a variable Clinical picture sith meniagitic or myalgie symptoms pre: dominating. It is possible that diferent strains. of virus fe associated with wifferent clinical features. and that the ‘Onford epidemic was caused by a virus diflering from that feurrent in Manchester of Edinburgh at the time. On the fther hand, itis well known that the same virus may cause both myalkie and meningiic illnesses “The understanding of the epidemiology of Bornholm disease, of aseptic meningitis, and of non-paralylic polio mnpelits in this countey may be expected 10 advance rapidly When more strains of the Coxsackie virus ate isolated and their immunological characters are worked out. ‘Summary In an outbreak of Bornholm disease # Coxsackie virus of Dalldort’s Group B was isolated from the facces of two of the children affected. A rise and fail in the titre of antibodies in the patients: sera indicated that they had suffered a recent infection with this virus. ur thanks are doe tothe physsians of the Roval Hospital for idk Children in Esinbungh under whose cae the children were: TeProtesor Ted. Mackie for help and advice: to Profesor A Murray Drennan’ for help mith the histology: to Dr R.A Cumming for samples of gamma elobulin to Me. 3. Sutheriand for"techsial helps. and 0 Mrs J. Toaaeson” for the supply of Mable liters of mice THE BACTERIAL CONTENT OF THE ALTHY HUMAN SMALL INTESTINE. : --OK JUDITH CREGAN, Se. NANCY J. HAYWARD, MSc, Ph.D. iFrem the Seliool of Racterologs. University of Melbourced ‘This work was undertaken to determine the number and kind of bacteria. that inbabit the healthy human Small intestine The results showed that their qumber is so smal that they must be regarded as transient con taminants passing through with the ingesta rather than 2 resident flora colonizing the tract, They are chiefly those Gram-positive species that are-usunlly found ix the mouth and throat. Experimental ‘Ciaieat ' Patients undergoing gynascologieal operations without ant ‘hilory. of disease ol the intestinal act or of iis associated organs were selected for the investigation, 18 very case no inflammatory process was proceeding in rhe ‘abdomen: the general health of the patients was good, and they were fasting for six houts before the operation. Collection of Specimens tn order thatthe sampling should be as precise as possible, intestinal contents were taken direct from the bowel with a Stringe when the abdomen was open at operation, The Sines necale was inserted vbliguely into the antimesenteric- border of the small Bowel Generally the bowel contained 50 fitle material that sample of i contents could be obtained only as a washing This was procured. by injesting 2 ma. of sterile Ringer's solution. (Ghosen. because ef ts Tow tosicity for micro Styantsms) favo the lumen of the bawel while consisting the bowel with the fingers about 1 in. @25 em) above and Iociow the site of injection; washing the bowel lumen. with the Mid by sucking it back and forth with the syringe: find then femoving the gesultant diluted intestinal contents, ‘Although these samples were diluted they were satisfactory because interest centred only on the relative numbers of| Srginisnis st various. anatomical levels of the intestinal © hict It was necessary only that the technique should be Uniform; therefore the same volume (2 ml) of Ringer's SStuvon way wsed. for ever washing, both for the small jncestine and for the mouth and large intestine when they ere sampled as controls. “This technique was fist practised by our colleague Me. FE, Dunlop. honorary. sureeen to the Royal Mefbourne Hospital who conchled that i was not prejdicial to the postoperative progress of the patient. This was confirmed Ey Professor Townsend in the present investigation; the postoperative course of the patients showed no evidence Bf leakage into the peritoneal cavity from the puncture of the bo: Racterologioal Examination of Specimens ‘The same technique was used for all specimens. and was designed to give both quantitative and qualitative informa tion about the Nora of the small intestine, Within a fewTune 20, 1953 hours of s2hi 13 the sample the following media were each ted with two drops (about 006 ml) of the bowel washings Sheep blood agar Jocotated 37" C. in {| Sheepblood gets st a McConkey’ agar Becrvont sexe fcubated 38 37° Chaney Shecp-lood agar Fee as. |” Steep-blood noteto esirset* agar 10% carbon donde | ‘The rajnge of media inoculated and the methods of incuba tion wees devised 10 provide the growth requirements of all species of bacteria likely to be found in the intestine, inclad= ing nonsporing anaerobes which have been reported 19: b= in large numbers in faeces (Sanborn, 1931 Torrey and Monn, 1931: Egserth and Gagnon, 1933), Generally the use ‘of specialized seletive media and techniques to detect particular species present in only small numbers Was pur Posely avoided because an overall piture of the flora Wis {esired, most importance being attached to organisms present iny largest numbers, "However, MacConkey"s agar and beer wort agar were included to detect coliforms and. yeasts respectively, The method of inoculation was to speeid the original ‘wo drops over an area at one side of the plate (A) and then to make three successive sets of four or five stokes AC right angles (B, C. and D), thus covering the whole rea of the plate. “The media were examined at intervals vp to at feast four days, and the degree of growth was recorded as follows: Grosth in seas A, B,C, and D. ‘wih in areas A, Baad C, not D Growth in areas A and By not Cand D Growth nly in atea A : No grant x = All species isolated were identified as fully as possible. ‘The systematic table recommended by Swift (1948) was used for streptococci, Three combinations of characters that id not ft any named species were encountered, and the Strains with these characters were called varieties 3, and 4 (Cregan, t0 be published). Staphylococes were named 4 ‘cording’ to the classfeation of Shaw, Sit, and. Cowan USI); and for Candida the classifications of Benham (1931) and Martin, Jones, Yao, and Lee (1937) were followed. Direct smears of all specimens were made by allowing four or fixe drops to dry in sitn on a. microscope slide. “They Were stained by Gram’s meikod, and the numbers and morphologies! types of organisms were recorded, These observations and’ the results of ‘culture generally. agreed The resulls by ditect smears were not included in the final assesement of the flora, but they provided a check on the adequacy of the media’ used for culture Results In assessing the quantitative Fesuits it was of theoretical importance (see Discussion) to decide the maximum number fof viable organisms that could be interpreted. as transient contaminants unable to multiply in the environment of the ‘url of the intestine sampled.” For example, in view of the Silution in Ringer's solution during sampling. i was neces: sry 10 know whether as large im amount of growth as indicated a transient Nora or whether it must be taken to indicate @ resident fora. To this end the contents of 190) rts of the alimentary tract Known to harbour a resident Mlora-the mouth andthe large intestine-were eamined quantitatively. The large intestine was sampled in the same Way’ as the sina intestine. in two erses from the eaccum and inv one front the transverse colon: and the mouth 95 “Sampled in five cases by senile rinsing with > sof Ringer's Solution. All the samples were examined by the same techy nique ws was used for the smalleintestine specimens. It Was found that the minimum degree of growth was ==. It Sane nd Revise 9ST, BACTERIAL CONTENT OF SMALL INTESTINE way concluded, therefore, that + or + growth could be interpreted as Weansient flora and ++ or +++ growth must be regarded as indicating a resident flora at the site sampled. The decision that + and 2 sronth are not due to the effect of dilution during sampling has been strengthened by later experience in tests of samples from the. small intestine in diseases of the digestive system (Cregan, Dunlop, Harrison and Hayward, fo be published). In some diseases the small intestine yielded ++ growth, showing that the method of sampling does not overdiluts the intestinal con fents when a flera is resident. Fourteen cases were included in the peesent investigation, and the sites sampled were the upper jejununs, the mide ful, and the lover Heum within 8 to 12 i. 0 to 30 em.) of the ileo-eaccal sphincter. The sites were determined by the anatomical appearance of the bowel and mesentery. The result are shown in the Table, Flora ofthe Sial teste uaniiaine atiatne Rea site = i 2 vam | See eae mn | ass ‘meanemeltt {Sigiecaagoq Tramiegon corn pauh, Revdontfoa oT SUERTE, ste etnies Botte Mtb inc ‘The maximum growth in any of the samples from the upper jeamuen and mid-gut was “+. In 22 of the 28 samples tno grolsth at ail occurred, It can be confidently concluded therefore. that these sites in the healthy individual are vir- tually sterile. Twelve of the 14 samples from the lower leurs yielded + oF less growth, indicating that in most cases the normal-lower ileum contains only transient oreanisms ‘The qualitative results set out jn the Table show that the few bucteria that contaminate the small intestine are_pre= dominantly Gram-positive species of the general type more fcammenty associated with the mouth than with the lower intestinal tract. However, in the two cases in which there Wasa resident flora in the lower ileum the organisms found There were of faecal type “The technique of sampling intestinal contents with a at operation in order to determine the flora of the ‘advantazes: (1) samples are taken bby a direct rovte, so that the risk of contamination is at a minimum: 2) the Tevel of the intestine sanipled can be Anatomically defined by ircct observation ; (3) patients ‘whose digestive tacts are completely normal can be included in the investiation >and (4) investigations can be made on the living subject. There are numerous reports of investigations of the flora of the small intestine in health and disease xing other tech= Fore Just 20, 1983 the mojorty—for example, most of the 14 references in German published Between 1912 and 128 and quoted By Licht 1939-30: Wenatlee and. Knott, 1924 Rogendortet, 19243 Knot, 1927; Thomson, Einhorn and Coleman, 1980. Kanaler 1932: Nichols and Glenn’ 1939) and Frage, 1089 samples have been obtained indvetly with tes of dt ferent kinds passed via the mouth, A disadvantage ofthis technique is that it exceedingly dificult to" ensure. that a specinen from the depths of the intestine is not gontamy nated with organisms Irom a Bigher level In addition, its evident, fom publised reports of relative engi of tubing land intestine, that the intestine cteeps up on the. rubber tubing: making it difeult to ascertain, excn approximately the anatomical level of the intestine sampled ‘A number of investzations have been made of specimens taken direct from identified levek by swabbing the himen Of the small Bowel when It fas been eaposed at atiet ‘operation for removal of a diseased adjoining part of the tiaet (Cushing and. Livingood. 1900" Henewon, 1904: Paulson, 1929; Barber and Franklin, 1946). Although this technique is inappticable to normal bowel, forthe Spey ot bowel dscase o whieh it applicable the fests are tell able_and informative. Normal hovel hs been examined ty ‘direct methods wihin twenty hours ot death (Garr 1925; Blacklock, Guthrie, and” Macpherson, 1997) bu i Appears, (See below) that -elable information Gould be ‘expected only within afew hours of death The techniques used in former investigations are all open to objections which ave overcome by the technique Used in the work reported ere The quantitative results Gee Table) showed tha the nor: sval smal intestine Is exceedingly sparsely populated or en Populated along is Whole length. This fndiog ty at variance With the results of stds of normal subjects tsing intestinal te. By intubation the duodenum vas found 1» be often sterile to contain very few miero-orsuniss (Venables and Knol 1924; Knott, 1927; Lich, 1929-302 Ranier, 1989), buts ther levels of the small intestine organisms, were found to bbe numerous. of the order of lions per millitveof ints tinal conten Bogenaorter-1524 Thomson and. olfers, 1930. ‘Nichols and Glenn. 1939). if one accepts the Bnd ings with the dzece sampling ochnigue reported here the ‘ests of intubation stages for the lower small inteing Imust be judged to be erroncous. "They. have misled the fenching over the last 30 sears preseming 8 picture of te Small intestine 2s an organ containing virtually no organisms ts upper end. bot atone its length progressively aequeing 4 flora, including coliforms, ttl at fe lower end st vey heavily populated. Thin Stevenson (1950) was misled ino siggesting that Bec. coll DA33(O1N) might be the noes Inhabitants of the duodentm or jeiunum. and Watther and Millwood 9S) carced out a serological investigation of Strains of Buc. col aolated from the duodene jena ne tion of 31 subjects after death shen tn fact tee af Bat coll an inhabitant of the upper or rae Realy Ising smatl intestine ut findings are confirmed, in part atleast, bythe results cof other workers with samples ‘removed iret fromthe bowel lumen at or after opsrationy tor intestinal dveare These consistently point 10 the conclason that generally the small intestines either ‘serie or contsing very ‘rzanisms along is Whole fength. The mow interesiag of these studies were esrred out 80 yeurs ago by Cushing and Livingnod.(1900) nthe Lied ‘Sates and by Hewstaon (900) Ta Great Britain. "On the basis of ver} careful bacteriology both investigations Hed 0 the conclusion that the upper and middle stall ntsines ate generally sete Cushing and: Liingood disingushng.beteeenpermancet and transient organiams.” Hewson rovotded. seme cise: in which the jeunum was sete although the stomach was contaminated Later, by direct swabbing, the ileum in three cases of ileostomy ‘was found by Paulson (1929) to contain only few Gram-positive Barber and Feanitia (1956) found thatthe Guodenum woe infected in onl? of $0 cates Jof peptic lace or gastric carcinoea The spper jejunum and id-zut were fount te sontain, if anything. otganinrs of ial type, pesdominanty septa: covet not Belonging to any ef Lansefiehls grips “ss Tbe) In the lover Hew 3 similar population wis found except ina minority of eis (2 out OF 13) in which organs BE fecal type Sete present. This ako is at vaviance with the ndings of most intubation investigation, in hich ole forms. althovah rare in the dodenum, were instesinaly common at progressively lower level of the smal intestine ‘The reslls of Blacklock and others (1987), ho sled the Jame sampling technique as curscives, bus who drcctod tele tention slmost soley to the detection coliforms sire in ment with our findings. They found that bacteria sere scam inthe small bowel and fled t0 detect eliorms in att of ine specimens from the upper jejunum and in 12 of 18 specimens from the lower ileum. "Samples taken within 12 houts of death contained colifoeny organisms sn ‘01 36 duodenal specimen, showing that almost the satire ath of the small intestine is favaded by organisms [rom the large intestine within 3 short time of death Since the smal intestine is invaded so soon afte death Jaw antibacterial mechanism must operate in the living small esting, The rests cf am investigation of the Nora of the nail itestine in cases of disease of the stomach (Cres, [Duriop, snd Hayward, to te published) show thatthe an bacteria mechanism of the small intewine is independent of the secretions of the stornach “The nature of this amibcteri! mechanism has not been investigated by us) Bogendorfer (192) reported that there ise thermolsbile-antibacteral substance, of lipoidal mature Sind of molecular size similar 40 eye albumen. in the juice find mucous membrane of human soll intestine This has not been confirmed, Blacklock and others (1937) ivest fated the claim that bacteriophages were responsible, but their results weve negative. Having dhconsed the hteratare they. could draw no definite conchision, and supposed that many factors combioed to Keep the svallintewine fey sere ‘Whatever the mechanisss—chemical, mechanical, or cella har—it ceases to be elfsctive in the region of the fico caecal sphincter. As in a minority of cases a protise flora off faccal type was found fa ths Jower sleum, # scoms that th| precise anatomical level at which she mechanism ceases. to| be effecive varies from person to person and possibly also] From time to time in the sime person. It does not operat felther in the environment of the large bows! or in the small bowel within a few hours of death, Summary ‘The bacterial flora of the healthy small intestine has been investigated, using samples removed from the lumen of the bowel with a syringe at gynaecological operations. ‘Tho results have shown that the whole length of the small intestine contains only 2 transient flora, chiefly of Gram-positive species that are more commonly associ= ated with the mouth than with the large intestine, From the apparent inability of these organisms to become resident-in he small intestine it is dedkced that fan antibacteris! mechanism. distinct from the stomach mechanism, must be operating there. ‘ue shanks ate due to Profe F 8. Le Tosensend, profesor of bsterss and aseaecoloas. Unierste of Alelbourne for tking the saps of iatestinal contents for ws. Without Mi wl ‘peration his investigation auld not have been pos sia! of the Women's Hospial, Mefbourne. ond (Miss Marorie Krol for technical asaivance. One of ws (C2) 30 in feelgt Sf 3 pergnal arant tom the Nasional Mesith am Medical Researeh CouncBACTERIAL CONTENT Juxe 20, 1953 nM. 8 2, tap Sees, BORE Ejeet noma, as, ocr Bie a. CHLORAMPHENICOL IN. PROPHYLAXIS OF INEANTIL GASTRO-ENTERITIS R. MeLAREN ToDD, M. Senior Lectarsr in Child Health, MRCP, DCH. University of Liverpoot EDWARD G. HALL, MB, Be, Patholosist, Alder Hey Children’s Hospital, Liverpoot Infantile sastro-enteritis is a condition which usually fects infants under the age of 1 year. It is charseiee, ized by diarthoes and vomiting, but other features such a5 anorexia and loss of weight may be present. In some cases iarthoea may be the only symptom, in others foxaemia and dehydration may be marked. and in others diarrhoea and vomiting tend to recur. After reviewing Rep reTeesed outbreaks of neonstal sastro-enterite Kirby er al. (1950) concluded that the term gastrot enteritis” had been applied to at least sin different Clinical syndromes. a jm some patients with clinical gastro-entertis, Salmon fila oF dvsentery organisms may be the causative agente, but in othsis no specific organisms have been isolated Since 1945 increasing attention has been paid. to the occurrence of specific serological types of Bacterium cath in both sporadic and epidemic infantile diarrhoea, god Fomiting. In some outbreaks there has been a relatively high correlation between the incidence of the disease and the isolation of these specific types of Bact. coli. Kites et al. studied an epidemic of neonatal gastro-enene associated with Bact. colf O 111 (133) and showed thar this organism might appear in the stools one to nine dese before the onset of symptoms. Breliminary reports (Rogers et af. 1959 ; Swellie, 1980) sugested that chloe Jamphenivol was of valu in the treaument of ‘seve enteritis, and our own experience over the pst We rears has confirmed the value oF the drug in estabtisned seri, Present twvestization This paper records ce With chnesmphenicot whom dizrthees. he OF SMALL INTESTINE Gevsloped, The investiations were undertaken between November, 1940. and August, 1951, in two of the Wards of the Liserpool University Departnient of Child Healthy oe Alder Hey Children’s Hospital. Liverpool, Thess wards gach containing 14 single cubicles, are used primarily fee the treatment of infants under the age of I year suferiog from gastro-entertis, but infants with other diseases arch 4& Fespiratory-tract infections are also adetied shee beak are availabl Recial swabs taken trom all infants on admission, and at intervals of not more than four days thereafter, were cerns ined for Bact. cali O11 according to the temniaue are ployed by Kirby er ol. (1980). Patients becoming cree infected with this organism but who had not develoned slatrhoea were included in the investigation, and alteretc patients (“triat” group) were given chloramphenicol dosage of 75 me. par Ib. (165 me. per ke) body wesht pet da, in divided doses three- or four-hour, for a pone ce seven days. The remaining cases ("control group) received ‘0 chloramphenicol. The day on which Beer eal Oe was firs isolated is referred to ce day 0 Sisty patients were observed, 30 in each group, but four Batients in the trial group Were subsequentiy cichuded er sause chloramphenicol was not given until more then three dass after the rectal swab became posiive Toe her ney on ‘The first dose of chloramphenicol was given on day 0 in sone ease, om day Yin 15 eases. and on ay’? in IO cases, 1a the one patient who cecsived chloramphenicol an dae) the drug was iniiatly prescribed because af symptoms sugieniee of whooping-coush. The details of age, disuse oo ook mmission. antibiove therapy, ete, are recanted tn Tables T and Ir Taste 1—Conmet Group | srecite Ther vetaaass | pao ae jp) 2 ime Br EA ne EP | # (pditteet [sopeatue | os | | | DEERE Se fawomen | ao | fo Bagi) = Bd say | peiges - pedo: (poe eee EOE omwous, Seeile | Acute beopehitis | subbing | Mesinguesest | slpelis