352 - bmj military health

352

THE CAUSE AND MEANS OF PREVENTION OF TONSILLITIS,

WITH SPECIAL REFERENCE TO NAVAL AND MILITARY SERVICE.

By TENAX PROPOSITI,

THE rising incidence of tonsillitis throughout the Army .has received a great deal of attention during the past few years. This problem is not one which is confined solely to the fighting services and a comparative study of statistics from other large communities is instructive, for i~ shows that the percentage of cases in the Army is not unusually high .

. In an epidemiological and statistical study, Sydenstricker [lJ has shown that. there has been a gradual, increase in the incidence of tonsillitis throughout the world since 1880. Dudley [2J has found the average number of cases per term at the Royal Naval School, Greenwich, to be 4'6 per cent. Glover [3J has recently quoted the figures of the committee of investigation into schools. Among 8,500 public school boys the incidence was 4 per cent per term. Among 3,000 girls under similar conditions it was again 4p'er cent. Close [4J gives the percentage of cases in 386,272 out-patients at Guy's Hospital as 6'7 per cent. The last figures have been spread over the period of ten years and the conditions of the local housing will account for the higher incidence; as all ages are included the figure 6'7 per cent is lower than might be anticipated. The figure for the Army at home [5J is again 4 per cent for admissions to hospital, so that it may be assumed that 4 per c,ent is a remarkably constant figure for the number of cases of tonsillitis in any community.

The title of this paper is the cause and means of prevention of tonsillitis. The cause is dealt with under three headings: the bacteriological, the environmental, and the personal factors. It is difficult to prevent these three headings overlapping as they are all intimately associated. Each is dealt with separately as far as possible.

THE BACTERIOLOGICAL FACTOR IN TONSILLITIS.

, This section is divided into two parts. The first deals with streptococci and their presence in the normal tonsil, the second with the relation of streptococci to tonsillitis.

Part I.-Streptococci.

, The evidence is growing ever more convincing that the important bacteriological factor in tonsillitis is the hffimolytic streptococcus.

Our knowledge of streptococci is intimately bound up with the history of their classification. The first attempts were based, on the ability of the various types of streptococci to ferment a long list of sugars.

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Gordon [6] published his classification in 1903. In 1906 he grouped. the streptococcal :ijora of the tonsil as follows:-

Streptococcus pyogenes salivarius anginosus jaJcalis pneumococcus

13 variants 13 25 11 18

Holman later used a more rigid classification, but onl'y added further names to the already formidable list. It is becoming more and more difficult to assess the clinical and pathological value of any particular strain.

In 1919 Brown [7J re-introduced an old and discarded classifica.tion based on the effect of streptococci on fresh blood in the blood-agar plates. This was an old method of Schotmuller who first described Streptococcus. hcemolyticus and Streptococcus viridans. Brown insisted on a verycareflll techniq).le and divided the streptococci into four groups. These are the alpha, alpha prime, beta, and gamma strains. As frequent reference will be made to these groups a short description of the action of the four strains on poured blood-agar plates. is given. This description is taken from a paper by Knott [8] in the Guy's Hospital Reports. ..

Alpha Strains.~There is a greenish discoloration and partial hremolysis of the blood-corpuscles immediately surrounding the colony, forming a" rather indefinitely bounded zone one to two millimetres in diameter, outside which is a second, narrow, clea,iei and not discoloured zone. When these colonies are examined by means of a low-power microscope, ma,ny corpuscles, discoloured but not hremolysed, are seen in the inner zone. Relativelyfew corpuscles remain in the narrow outer zone. The outer zone increases 'when, after incubation, the plate is kept in the ice"chest ..

Alpha Prime Btrains.-A zone of hremolysis; which is slightly hazy, surrounds the colonies and is less sharply defined than in the case of the true beta hremolysis. The colony is not very sharply defined and the zO.Qe contains moderate numbers of unaltered corpuscles. There is no greenish discoloration. Unlike the beta hremolysis, considerable extensions of .the zones may occur when the plates are kept in the ice~box ..

Beta Strains.-The colonies are surrounded by a sharply defined, clear, colourless zone of hremolysis two. to four millimetres in diameter~ No corpuscles can be seen .within this zone; it develops more quickly than that of the alpha type, ,often being well-developed· after eighteenh'ours incubation. No increase in the beta zone occurs in the ice-chest. .

Gamma.Strains.-The colonies develop on the blood-agar, wi~hout producing any visible change in the medium. c • • ...

In this classification the old Str. hmrnolyticus is included in the beta hremolytic group, and the Str. viridans in the alpha group. Amongst the gamma. strains are included Str. fmcaZis, Str. salivarius, Str. mitis, etc. The important point is that the beta strain is highly pathogenic, the alpha mildly so, while the gamma strains are essentiaUysaprophytic. The

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evidence is increasing every day that the only bacteriological factor of real importance in tonsillitis is the beta hremolytic streptococcus.

Stieptococci of the Normal Th'roat.

It is a matter of every day experience that a great variety of organisms can be recovered from a swab of the normal throat. Davis [9J has found streptococci, staphylococci, pneumococci, meningococci, and diphtheroids. Shipley, Hangar, and Dochez [10J state that tbe basic flora of tbe normal throat incl.udes Gram-negative cocci, non-bremolytic streptococci, large Gram~positive cocci, Bacillus injluenzce, and diphtheroids, with a transient flora of Staphylococcus albus, hremolytic streptococci, Staphylococcus aureus, Staphylococcus citreus, and pneumococci.

The streptococcal flora of the normal tonsil has received a great deal of attention. In 567 persons Tongs [l1J found 67 per cent showed the presence of tbe Streptococcus ha:molyticus. Davis. [12J llas demonstrated that repeated cultures taken from the throats of normal adults at intervals showed the presence of hremolytic streptococci sooner or later. Arnold [13] finds the presence of hremolytic streptococci in normal people to vary between 15 and 100 per cent. Walker's [14] work on Army recruits is 6f interest in that it deals with military conditions. Although streptococcus disease was absent during tbe investigation, 16 to 20 per cent of recruits showed the presence of a hremolytic strain. A similar figure was obtained from the permanent personnel. Beattie [15J has found the hremolytic streptococcus in 92 per cent of tonsillar crypts.

Bloomfield [16] finds two main groups of organisms in the normal throat. r:rbe first is constantly present and consists of Gram-negative cocci and nonhremolytic streptococci. The second is transient and consists of pneumococci and hreillophilic bacteria. In 1921, working on the throats of infants, Bloomfield found a very simple bacterial type consisting of:-

(1) Staphylococci, introduced by feeding and recoverable from the nipple of the nursing mother.

(2) N on-hremolytic streptococci. (3) A few Gram-negative cocci and diphtheroids. Hremolytic streptococci were never found in infancy. This agrees with

the common clinical experience that tonsillitis is most unusual below the age of five years. Close [4J and Lay ton [17], have both stressed this fact.

The importance of distinguishing tbe patbogenic beta type from the nonpathogenic alpha types has been pointed out by Bloomfield. In the course of a repeated andvery.closely controlled study of an epidemic of influenza, a widespread. distribution of alpha prime forms was found, but no increase in beta hremolytic forms. Cases of tonsillitis did not show a rise in incidence: This is in conformity with the experience of the Army [5] during the epidemic of influenza in the Eastern Command in 1928 when tbe following figures were obtained :-


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Tenax Propositi

1928 93'2 51'4

1929

.10'1 54'0

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The evidence strongly suggests that thehffimolytic streptococcus' was absent from the throats in these particular outbreaks of influenza.

Eves and Watson [18J have worked on tbe throats of 450 school children taken from three schools. The ages varied between 11 and 20. They found the hffimolytic streptococcus to occur in. the throats of 58, 75, and 84 per cent respectively in the three groups.

Shipley, Hangar, and Dochez [10J have found a striking increase in the incidence of the hffimolytic streptococcus in the tbroat during the winter months, when throat infections were most prevalent.

Fox and Stone [20J 'have shown that the presence of the hffimolytic streptococcus may be frequently un associated with symptoms in' the carrier, but associated with colds, influenza, etc., in other members of the community. In almost every case where pathological conditions were present, the hffimolytic streptococcus was detected. McCartney [21] findstbe hffimolytic streptococcus to be abundantly present in acute :inflammatory conditions of the throats of children. Thomson and Thomson [22J have made a complete study of the literature and carried out some extensive photographic work. They have found the hoomolytic streptococcus to be of the greatest importance in the cause of tonsillitis, but the presence of the following organisms is also a considerable factor: Micro~ coccus catarrhalis, Staphylococcus aureus, Bacillus influenza, pneumococci, and Gram-negative bacilli.

Part II.-Streptococci in Tonsillitis.

The evidence that the bffimolytic streptococcus is the important bacterial factor in tonsillitis is convincing.

Young and Crooks [28] have investigated a large number of throat swabs from acute cases. Hffilnolytic streptococci were obtained in 80 per cent of cases which were not diphtheritic in origin.

Bloomfield and Felty [16J and Hodges have carried out a most painstaking and controlled series of experiments on the incidence and spread of tonsillitis amongst 200 nurses of the J ohns Hopkins Hospital. Three cultures from each member of the group were made in meat infusion broth and poured on 5 per cent human blood meat infusion agar (pH. 7'4). 28'7 per cent gave a positive growth of the hffimolytic streptococcus. The resultsof their investigations were :-

(1) That the focus of infection was the tonsil, and that bacteria did not actually grow on the surface of the tonsil except by accident.

(2) That the number of streptococci obtained in the culture bore no relation to the clinical signs,

(3) That in no case of clinical tonsillitis was the hffimolytic streptococcus absent.


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(4) That the absence of the hremolytic streptococcus was strong evidence that the case was either diphtheria or Vincentls angina.

Later, the same authors have' produced convincing evidence that tonsillitis is specifically due to the hremolytic streptococcus. Other streptococci, staphylococci, and pneumococci are present but merely saprophytic. MacCallum puts the blame on, to the viridans strain, but Felty, and Hodges have shown this organism to be a normal inhabitant of the throat., The hremolytic streptococcus persists in the crypts long, after the acute infection is over. Nakamura [:25] has supported this by finding a high incidence of hremolytic organisms in the crypts of tonsils removed during the winter months.

In their series of cases, Bloomfield and FeIty found at least four strains of beta hremolytic streptococcus to be causative factors, whilst a still greater variety of strains of streptococci occurred as parasites among carners.

Richey [24] investigated 155 volunteers,using the secretion ,obtained, from th.e nose in cases of influenza. The secretion was filtered and instilled into the nose; no infection occurred. When crude secretion was l"!sed, sixteen of the group developed acute tonsillitis from which a hremolytic streptococcus was subsequently recovered.

J ulianelle [26] has recorded the bacteriology of 147 cases of hypertrophied tonsils in which the hremolytic streptococcus was found' in 90'4 per cent; staphylococci in 62'5 per cent, and Streptococcus viridims in 51'2 per cent. Harnbrecht and Nuzum [27J examined 218 cases, of which 63 per cent gave a history of repeated sore throats. Pathological changes of the tonsils were present in 93 per cent. Further, 96 per cent of these infected throats showed the presence of streptococci, which predominated in 85 per ce,nt.

In Vienna, Waldapfel [28J has attacked, the problem from a different angle. He injected himself with twenty cubic centimetres of defibrinated blood from a patient suffering from acute tonsillitis and also rubbed a smear from the patient's tonsil on to his own throat. Both experiments gave

, negative results. Waldapfel qoncludes ;-(1) That tonsillitis cannot be transferred from t.onsil to tonsil by inocu

lation directly, or by the transfusion of blood from a patient to a healthy normal. ' : '(2) That the phagocytic powers of the blood are increased as a result of acute infection. " . ' \

. (3) That this phagocytosis is specific for the particular strain of infecting streptQcOGcus. , , (4) That the streptococcus present is not accidental but in close relation to t.he dise~s~and its course. The factor which precipitates the onset of "acute infection is unknown, but is attributed to some febrile cOt;ldition, ,sucl;1 as, a co~d, :Wl1ichupsets the biological equilibrium of the body .. , '.' ' . Polvogtan<1Crowe [29] have found that throat cultures taken. during


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the winter months showed 91 per cent of hremolytic streptococci. Fifty per cent of the cases showing the hremolytic streptococcus were children under 11 years. The majority of the cases in which the staphylococcus was predominant were over twenty-five years of age. Cobe [30J inv~stigated 400 .cultures and found the streptococcus to predominate. Hremolytic streptococci came second in incidence, followed by pneumococci in order of impor:tance.

Thomson and . Tho~son [22J have shown that the. infecting type of streptococcus does not remain constant, but varies from week to week. They have nbt found the hremolytic strains to be very common, but viridans types to be numerous. Gram-negative cocci of the catarrhalis group are always present. From the results of their photographic work, they have not incriminated any one organism, but. have suggested that there are a large number of tonsillar infections in which various types of streptococci play the most important retiological role. Other .bacteria. such as Micrococcus catarrhalis, Staphylococcus aureus, Bacillus injluenzce,. pneumococci, and Gram-negative bacilli·of the colon group are also incriminated. In this series, the pus from the yellow pin-point abscesses of .follicular tonsillitis has seldom yielded a growth of hremolytic streptococci. Agreen-producing organism of the viridans type has been suggested . as probably the most important causative bacterial factor. This work has been done with such a wealth of photographic detail that considerable doubt .seemed to be cast on the importance of thehremolytictypes, but the recent paper of Glover and Griffiths seems to have put the issue beyond doubt,!These authors have obtained a growth of hremolytic streptococci in abundance, sometimes almost a pure culture, from every case of acute tonsillitis. . Working on material from schools, they have found the result of infection to depend on the size of the infecting dose, the state of immunity of the.patienL, and the pathogenicity of the infecting strain.

It may be concluded from the figures already given that the important bacteriological factor in acute tonsillitis is the hoomolytic streptococcus.

The Army Medical Services [5J have done a great deal of work on tonsillitis from the pathological standpoint, .but the results have been disappointing. Vaccines have not proved to be a success and no causal organism has been identified. It seems probable .that the weak link in the chain lies in the technique of taking the throat swabs. . Some workers have evolved a most rigid technique to obtain successful results. Salivary contamination makes any further work valueless. The most satisfactory results have always been obtained when the bacteriologist takes the swabs himself. It seems probable that medical officers do not appreciate that a good light, a tongue depressor, and great care are essential. to ensure that salivary contamination does not spoil the specimen for further examination. Of such importance is this technique .that some workers! have. resorted. to tonsillar puncture in order to avoid contamination. A. haphazard .wipe: in the dark is. worse than useless. After a careful study of the literature, I: am convinced that this is the cause of unsatisfactory results in the past.


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TaE ENVIRONMENTAL FACTOR;

That adequate spacing of beds is necessary for the prevention of the . spread of saliva-borne disease has been recognized for many years. The work of Glover 'on the spread of cerebrospinal meningitis has put this practical knowledge on a scientific basis. Glover [31] showed that a distance of two and a half ·feet between beds was sufficient to prevent the dissemination of meningococci during eight hours' sleep. Dudley [2] has carried

, out very careful work at the Royal Naval School, Greenwich. He has found infection to take place only over very short distances, although microorganisms may travel over thirty feet from the source of infection by droplet spread. . The smaller the room, the greater is the, likelihood of infection. If the concentration of organisms is small, infection does not take place.

Dudley has explained that in droplet infection by talking, coughing,and sneezing there are two separate and important factors. The particles projected by a cough consist of two types, heavy and light. A cough produces a jet which travels almost instantaneously for a distance of one to two feet, when the resistance of the air stops it. The heavy particles rapidly fall to the ground. The light particles remain floating about in the air for a long time, up to perhaps half an hour. It is the heavy, salivacarrying, short range jet of heavy droplets which is'the important infecting factor. .

Professor Bulloch used a suspension of Bacillus p1·odigiosus. In a series 'of experiments, he was able to recover the same organism from a subject forty feet away from the source.

Some organisms are recoverable from the light air-borne particles. If the heavy, short-range jet of particles is the important factor, although organisms may be recovered from the lighter droplets, what are the factors which determine that infection is transmitted by the former method almost exclusively? To explain this difference Dudley has introduced two other factors, a time factor and the theory of the minimum infective dose.

As regards the first, infection does not take place during the short period of contact at drill or in the dining hall, but during the more prolonged and intimate association in the dormitory. It is possible to travel for perhaps half an hour a day in company with a carrier without becoming infected, wbilstcontact during three hours in the theatre will allow sufficient contact for infection to occur. This is the hypothetical case given as an example.

The theory of the minimum infective dose has been evolved to explain the different. possibilities of infection .. A certain mass of infecting agent is necessary to produce an iJlness, and this mass is received by an individual at variolls rates. The individual can destroy the infecting agenlt at a certalD rate, and the power of tl'le recipirent to destroy the amount of the infecting agent may be positive or negative. If negative; illness win supervene p.rovided that the subject of infection stays long enough near to the source Of infection. The greater the negative· difference, the less is the time


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required to produce a case or a carrier. The difference between the rate of reception and destruction of micro-organisms is termed the velocity of infection. This theory seems to explain why there is such difference of opinion between authorities as to the value of droplet infection in the spread of the saliva-borne disease. 1£ droplet infection is taken to mean only the heavy particle method of spread, there will be general agreement that very close contact is necessary to produce infection.

Bloomfield and Felty [16J have found the spread of tonsillitis to depend on extremely close and prolonged contact. This intimate contact was found to occur in nurses in small dormitories during off-duty hours. The nurses would gather. in small groups for several hours, talking, coughing and eating.

Flugges' experiments with suspensions of Bacillus 'I}rodigiosus showed that few, or no, bacteria left the mouth during quiet talking1 but that vigorous coughing expelled them for varying distances up to nine metres, depending on the local conditions. Bloomfield and Felty have repeated these experiments, and have gone further by swabbing the organism onto the pharynx and tonsil, instead of the lips and anterior part of the tongue. They have'shown that when infectious material was carefully placed on the tonsil, the most violent coughing and sneezing failed to expel more than an occaSIOnal organism. Organisms on the tonsil gradually become transferred to the anterior part of the tongue during the ordinary movements of deglutition. Such a transference was shown to take place onJy rarely. A further investigation to attempt to recover the infecting organism from the air surrounding the patient was unsuccessful. They-concluded that very close contact was necessary to allow the spread of infection from carrier to contact.

It is most difficult to trace the path of direct infection from case to case. I have gone carefully into all recent cases occurring amongs,t troops and families, and have been able to trace the infection in only three cases. In all of these'there was direct evidence of close and prolonged contact. In one case the two children slept in the same bed. In another, both of an engaged couple acquired acute tonsillitis, the girl subsequently proving to be a carrier. In the third case, a mother infected two children so severely that a baby, aged 14 months, died of streptococcal septicremia and a boy, aged 7 years, was severely ill with a spreading inflammation of the throat, and very~narrowly escaped tracheotomy. The mother was subsequently shown to be a carrier of the hremolytic streptococcus. In no other cases have I been able to trace infection.

, Having established that close and prolonged contact-is necessary for the spread of acute tonsillitis, what are the factors which influence such contact so far as the soldier is concerned? These factors have been grouped under the following sub-heads: climate, epidemics, season, temperature, humidity, weather, rainfall, housing, habits,smells, messing arrangemen:ts.

(1) Climate,-Ithas been the custom toassunie that tonsillar infections abroad are due to dust-borne infection, and at home to droplet infection iri

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the barrack rooni. That the dust-laden air of the East is heavily infected is beyond question, but it would appear that the carrier-rate is still more important.' :The North Chiria area has seasons when dust storms are frequent .. These storms are of sufficient intensity to cause" Tientsin throat," but this is a dry pharyrigitis and' not. true follicular tonsillitis. After careful study of the climatic conditions and the incidence of tonsillitis at home and abroad, it would appear that there is no close connection betV\!een the' climate and tonsillitis. The carrier-rate still' seems to be a more' important factor.

(2) Epidemics.-True epidemic tonsillitis is always milk"borne. Many examples have been given in the literature' from all parts of the world. Control of the'milk supply has always been followed by a. rapid subsidence of ,the epidemic.; Such epidemics do not affect the ordinary incidence of tonsillitis, but they are apt to be severe ,while they last. It is unlikely that the infection of the ordinary case is milk~bcirne.

(3)Season.-Sydens!triGlrer's [1] extensive paper has shown that the seasonal incidence:of tonsillitis throughout. the world is remarkably constant. With one exception, the,re is' close agreement on this .point. Clifford Allbutt [32J writes that most ,cases occur in the middle of the summer, but there are no figures to support this statement. Olose fipds the peak of the monthly graph to be in October; Polvog~ ,a,nd .Crowe [29J find it in the autumn. Hodges shows the monthlY,curve to show a gradual rise in October, remaining high through November, December,J anuary, February, an:d, :Marcli, with a, fall in ApriJ •• In North Chin~, ,exactly the same curve is obtaiPed, although the dust storms occuressEmtially in February.and March. This fact suggests that the carrier problem is of greater 00 .iological imp(j)rtance)than dust-borne infection~

(~), :We:mperature.,-Hodgeshas observed the variations in the daily meaQ teIllpeJ,'ature for~ period of sevel} months,: but has failed to show any relation to,· the incidence of tonsillitis. Close could find no' connection bet~eeJ;l ple monthly ll!ean te~perature or the daily variation in his series. Nor.thChina has unusual climatic conditions; there is a .hotsummer and.. an intensely coldwint~r. The winter lasts for, three months; during which period, the daily, temperature remains below zero frequen,tly for days on end. The. temperature in July and August may rise to 110°. F. Very few cases occ~rduring the hot months among the troops left in the cities()f Tien~sin and Peking. The cold months also do not show a high incid'ence of cases. There has .been a steady fall in tonsillitis during the past fiv.e years. The ho~pital records do .notgo back for more than five years, but the expl~nation of the marked fall is probably due to improvelll~nts in the housing .. 'rh1S factor is dealt with later .. The more the figures are studied the more they suggest that temperature has. little effect, on the incidence of tonsillar infection.

(5) ,JIumidity. ___ :N<:lither IIo~ges nor Close has found any connection betw~en the relative humidity and tonsillitis. Tbe air of North China


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is intensely dry, .and cases of dry pha.ryngitis are common. This is partly due to the central' heating wliiciJ. is universal and essential for reasonable comfort, and partly to the intensely dry air. TruE'. tonsillitis is not unduly

. common. .. (6) Weather.-The majority of .textbooks state that exposure to cold

and wet is important, but this' has. not been brought out in statistics. Hodgeshas demonstrated that there is no relation between tonsillitis and changes in the weather or exposure to wet and cold. Beveridge [33J has pointed out that tonsillitis was not.a common cause of sickness in the front line trenches of Fratlce, where exposure to cold, wet and damp were frequent and unavoidable.

(7) Rainfall;-Hodges finds no relationship between tonsillar infections and the rainfall. The' figures of Close suggest that the number of cases taken over monthly periods varies inversely with the rainfall. . When the rainfall is high, tonsillitis is comparatively low. Further, there is no doubt that the Western Command at home . always shows the lowest incidence of tonsillitis. The average rainfall of the west coast. varies between forty to sixtY. .inches per annum; that of the eastern area of England is thirty inches. Rain in North China is a rarity and of .only very short duration, so that any 90nclusions are valueless ; but most of the. rain comes in August, w:hen a monthly graph shows tonsillitis to be almost non-existent.. .

(8) Housing.-Something has already been said on this aspect of ,the spread .ofinfectioll. 101924, an investigation carried out in Scotland showed tbatthe incidence. of .tonsillitis among troops in old barracks was greater than that in new"otherfactors being equal. It was hoped that rebuilding, decorating, and spacing in. barrack rooms would he followed by a.corresponding subsidence of· cases. Unfortunately, this has not been the case, and we must look elsewhere for the cause.

That satisfactory housing is of importance has been shown beyond doubt during the. past few years in Tientsin. In] 92.7 a second battalion was sent to the area during the disturbances of that year. The new battalion was hQused in converted warehouses of the most unsatisfactory type as ,no other accommodation was available. These warehouses, or godowns, were .overcrowded and Qverheated .. There were no recreational facilities or conveniences. Each new battalion, as it arrived, ~pent one year in the godowns. It was then. moved to the permanent, brick..; built, British infantry barracks on the departure of the previous battalion which had completed the, two-year tour in Tientsm. . Each new arrival ~had a large numher of cases of saliva-borne disease. During seven months in 1927, the Border Regiment had· 44. cases in the godowns; the East Yorkshire regiment .inthe permanent barracks had 12. Later, the Royal Scots had 71 cases during their stay in the. godown, and 43 for their year in the barracks. As . a final example, the 93rd Highlanders spent four months in the godown before the garrison was reduced . to .the normal size


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and the second battalion evacuated; During this time they had 69 cases of saliva-borne disease, whilst the Royal Scots in the permanent barracks had 23 cases.

The messing arrangements, institutes and facilities for sport and recreation were all most unsatisfactory.

Glover [3J has· recently pointed out that the incidence of tonsillitis in public schools is becoming a serious problem. This incidence is probably due to overcrowding ,of the dormitories consequent upon the increased demand for· this class of education. The figures of the ,committee of investigation have already been quoted.

Bloomfield and Felty [16] have found the cause of the spread in their series of cases among the nursing staff of the J ohns Hopkins Hospital to be due to intense overcrowding in small dormitories during the winter months. When off duty the nurses would gather together and sit for hours talking, laughing and eating. Prolonged contact was the rule. With the advent of the warm summer season, overcrowding ceased and tonsillitis gradually faded away. Bloomfield and Felty have also found, as Dudley [34] has pointed out,that contact during assemblies in wards and in dining halls is insufficient to cause infection. Both Dudleyand Glover [31 'have stressed the fact that· the incidence of' tonsilliti~ i~ far higher a~ong boarders than day boys. This fact suggests very strongly that infection occurs in the dormitory.

(9) Habits.-Habits are difficult to assess. There is a common tendency in any herd or community to forgather for warmth and company. It is under such conditions that infection occurs. The theatre and the cinema provide excellent conditions· for close and prolonged contact. There is no doubt that the einema has become' increasingly popular among troops during the past decade.. The talking film is practically as good as a theatre, and many men go regularly once or twice a week. The air of the cinema has been shown to be grossly contaminated, and the warm, moist atmosphere combined with remarkably close contact is more than enough to allow infection to occnr. I believe that a greater percentage of men visit the cinema regularly in the London District than in any other Command. The films are newer and more skilfully advertised than elsewhere. Further, the· cinema is a forin of amusement which the soldier can afford.

'This would seem to be the reason for the high incidence of tonsillar infections in the Eastern Command. It is unlikely tbat any decrease will be noted jn that Command. In fact, it seems that a further rise may occur owing to the improvement in the production of films.

Swimming baths have. always been blamed as a source of infection; That a tank may be a suitable medium for iiIfectionto occur is apparent. The picture of an infected swimmer leaving a trail of organisms behind him is attractive, to visualize, and most authorities agree that infection commonly takes place in such conditions. In Peking, a plunge bath was erected for the 200 men of the Legation. Guard. >Many of the men practically


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lived in th~,bath during July and August.. The water could not be changed more often than once a week, and the conditions were ideal for throat infections to spread. rronsillitis, however, was not common. There were many cases of inflammation of the external auditory canal. Some men complained of slight soreness of the throat, bnt this was probably due to over-chlorination of the water on one or two occasions. Although an infected swimmer must leave organisms behind him, it Reems likely that the theory of the minimum .infective dose applies in this case, not enough ma.terial being received by the potential case to allow clil1ical signs to ' appear. Even in a small bath organisms must be in a very dilute suspension. . In 1924, Smiley [35J investigated tbeeffect of the following factorsjn

the prevention, or encouragement, of infection in young students: tobacco, dust, gas, mouth-breathing, sleep, draughts. constipation, perspiration, bathing, and foot-weal'. N one of these factors seemed to influence the Incidence of infection. Cigarette smoking has been blamed in. the past for an increase in tonsillitis, but there is no evidence that such a contention has any scientific basis.

(10) Smells.-There is a time-honoured statement in many textbooks, supported by popular opinion, that the close proximity of a persistently bad smell has a bearing on tonsillitis. Thomson and Thoruson [22] have recently stated that while there is no known method of measuring a smell, yet there does seem to be some basis for. the assumption that there is such a connection; In Tientsin, there is one particularly foul creek running through part of the British Concession which has been blamed for cases of tonsillitis in the neighbourhood for many years.

(11) Messing. Arrangements.-The recent paper of Cumming [36] on the spread and control of saliva-borne disease has created a great deal of comment and interest. The main contention of the paper is that inadequate sterilization of mess-kits is responsible for the spread of disease, especiaUy influenza. Nichols [49] has already carried out some work on this aspect of the subject. He found that the hremolytic streptococcus was not sprea.d by dish-water as long as the reaction of the water remained about pH S'5, and the. soap was adequate. Cumming has emphasized that the problem mus.t be at.tacked by blocking the transmission from carrier to susceptible. 4n extensive series. of figures showed that the incidence of influenza among troops who washed their mess-kit by the usual lukewarm method was five times as great as the incidence among, those who employed collective efficient sterilization. One group used water at 70-100° F . and the other lukewarm water. The ratio of cases of influenza was as 1 ~ 6'2, eighty-five per. cent of the cases occurring among the unprotected group.

Cumming bas given the five-link chain of infection as;-

'Hands Hands Oral cavity/' ........ M k· t/' ........ Oral cavity of e s s- 1 of car r i er· wash-water susceptible

........ Mess-kit/" ........ Mess-kit/'


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364 The Oause and Means ,of Prevention of 'Tonsillitis

Organisms were found in the various stages of the chain as follows :-,H and s Ha n d s,

Oral cavity...... 33 % 'M k' t/' 45 % Oral cavity of e s s- 1 of

, wash-water t'bl car r 1 er. 66 % " suscep 1 e 53 % 'Mess-kit/' 0 Mess-kit""'" 34 %

16,% 72 % These figures were obtained from a control group using suspensions of

Bacillus prodigiosus. Turning to civilian conditions, it was found that among 17,000 people

using machine-washed dishes the incidence of influenza was 20 cases per 1,000. A.mong4,175 who used hand-washing, the rate was 10::3 per 1,000. There is strong evidence that tuberculosis is spread by infected table-ware.

The use of boiling water for sterilization was shown to reduce the number of organisms by 99'98 per cent. Seventy-eight percent of organisms were removed from spoons by hand-washing, and 99 per cent by machinewashing. Further, of thirty~two specimens of wash-water, using the hand method, ·84 per cent showed Streptococcus hrBlnolyticns, and 65 per cen t Streptococcus viridans. .

Thirty-eight per cent of cultures from the hands of carriers and cases gave a positivegrowtb, 340 examinations being made.

Cumming quotes Floyd and Fotheringham, wbo stated tbat " the belief is constantly growing tbat tuberculosis, and probably all so-called air-borne diseases are, in the majority of cases, hand-to-mouth or ingestion infections.

These investigations have created a great deal of interest.'rhompson [37], at Aldershot, has come to the following conclusions; (1) That there appears to be a definite relationship between efficient sterilization of mess-kits and a low rate of influenza.; (2) that contamination of. the wa,sh-wateris of considerarbl~ importance; (3) that" pin king " of the water is valueless.

The British soldier has his own knife, fork, spoon and mug, which he retains and cleanses himself. The plate is usually the property of the mess. In canteens, where common property is used, it is not easy to get the staff to carry out the necessary sterilization owing to the difficulty of obtaining an adequate supply of hot water, the want of co-operation, and tbe danger of cracking the glasses. Unless tberais constant supervision, preventive measures are scamped, and are regarded as an unnecessary precaution on the part of the medical authorities. Apart from what can be done in the canteen, it must be appreciated that the amount of eating and drinking which goes on intbe small cafe and bar outside the barracks is probably far greater thanLthat in tbe N .A.A.F.1. Any good preventive measures taken in barracks are usually rendered valueless owing to tbis fact.

That the substitution of mechanical sterilization for the present method would have a beneficial effect on the spread of saliva-borne disease is beyond question. All eating and drinking utensils would have to become the property of the mess. Unfortunately, the present financial crisis will not allow such costly methods of installation. Further, unless mecbanical sterilization is carried out in the surroundlUg area, any good effect is going to be largely balanced by infection outside barracks~

(To be continued.)


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352 - bmj military health

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