militaryhealth.bmj.com · usuapy di~appeaied'after'thr(3e to seven days. ' Thestra,ins were ,...

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A, BACTERIOLOGICAL ExAMINATION OF CONVALES,- ' CE N T S FROM' THE MEDITERRANEi\.N ._EXPE'-, DIf'IONARY FORCE.

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FROM TIlE' PATHOr.OGICAL LABORATORY OF T_HE UNIVERSITY OF'

MANCHESTER • . ~ - , ,

By H. R. DEA:rs:, R. S. ADAMSON, J, D. GILES 'AND R. WILLIAMSON.,

(Report to ~Medical Research Oommittee.L' " , .... ". \.. .-

"ALL therilateriai on Which this repo~,t is baSed was obt_ained ' from ,488 m~h, invalided from , theMediter~anean ~xpeditionary' ,,' ' Force for enteric fever or dysentery. , Tbe majortty of cases came from the Gallipqli Peninsula.' ,These 488 pati'ents, ,forming' a portion of the large number of enteric and dysep.tery convalescents, : admitted to the 2nd ,Western General Hospital, ,were sent to the Hope Auxiliary Military Hospital. 'Almost all tpe cases were convalescent and very few exhibited any signs of intestinal trouble. " In the majority of cases the regulation examinations ,of the

, freces and urine were, carried out; that is to say-;:-six bacteriological , examinations of frece:s and urIne for enteric, and ,threebacterio

logical and three protozoological eX~ll1inations for dysentery patients., , Some of thepa,tients were removed from Hope Hospital before'

the full number o(examinatiQns had been completed. ,The r~sults' of our examInations' showed 'that the bacteriological finding diq hot in .every case" agree with ,the original diagnosis. Acting on " this ,result we undertook a micr~scopical examination of freces from-259 cases of enteric convalescents. In seven of these cases the Entammba hist~lytic~ w'as discovered. The sera of. 317 cases were' examined for agglU:tinins against Bacillus- typhosus, B., paratyphosus A, B.' paratyphosus B, and B. dysenteriee (Shiga). We were only able to examine 190 of'the sera against B. dysenterice Y; as. we had great' difficulty in ~btaining a strain of this bacillus which wa:s satisf~ctory for the purpose.'

METHODS.

,Bacte)·ia.-Both freces and urine were, plated' onMacConkey?~ neutral red lactose biie salt agar ~edium. Subcultures were given a pretiminary examination' by testing'theirreactio,IiS in 'broth, litmul? milk and cane sugar,glucose,"}actose, and ma.~nit~ peptone

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H.' Dean~ ,E'. Adamson, 'J. Giles and'B. ,Williq,nwJn 429,' . . \. ' ". -, -

water.>The broth cuIturewas 'exa~inedafter twenty~four h0ur~ 'I, '

, :£61' motility and after five days for the presence oHndol. ,Strains, '\ whi~h corresponded in .this, liinityd, seri,esof reactions wi~htl;H>se ~,

. of- 'the, known pathogenic ~pecie~'.were tested by the agglutination ,reaction. ' , In these' :tests 'an einuls{onof: a stock strain of the ' homologo~s bacillus wasin~ariably ,emplbyedasa control. " " '

" ,Agglutination.-The macroscopip method was, employed. ,'In., .the maj01;ity .crcases ,the blood was obtained from an arm vein. "The, 'serllm was separated' afte~, twenty-four hOl1rs;" The, ?ilutions' were ,madewith:gradu~ted' pipettes. Each serum ,dillltion was' made up to a, bulk 'of one, cubic~ centimetre: To each' cubic centimetre 'of~diiuted serum there was added one cubic 'centl~etre of bac~ .

" te~ial em~lsion.' ;The tubes were left 'attjL'OOl~ temperature arid the res.ults were read after twenty-fo'ur hours. ,:The degree of agglutina-

__ tien w~s judged by ,the naked eye.,\Theh(1cterial emulsions were, prepared by rubl?ing llP twenty-four hour cultures of stock strains> in saline solution,' 'The sfock emulsions were treated with formalin.

'('The stock' strain:s of typhoid and paratyphoid A and '~' were, iaborat<;>rycultures, which have been used by oneo! us for many years for ser:umWork.- " 'l'he ~ culture of' Y bacillus was sent to us by Dr.W.\ J. 'Penfold,that of .the Shiga bacillus by Miss Chick of: the Lister Institute~ All these strains were very carefully tested. ; This isa matter; of somtninportance' as some strains of para: typhoid and dysentery bacilli are readily agglutinated by normal' sera in ,10wdilutioIl (1 in 2~ to ,1 in '100), although the control tube which Gontains the emulsion without serum may show no t:t;ace- of agglutination. From these strains we prepared antisera by the iritravenods inqculation of rabbits., Stoyk dilutions 'of antiseruni in saline solution, containing 0'5 per cent carbolic acid as ' recommended by :Ledingham and Penfold (1915) were found to:effect a consider 'able ecqnomy. \ , ,,- , ' ,: '" ", "

B. PARATYPHo.SDB A,

, These strains,fermented glucose and manI*e but had no action , on cane sugar an~Jactose. Gas formation on glucose and mannite,

was' slow and amounted to' no more'than a,'small bubble after seven days.' Thlt bacilli were motile ,and, did' not produce- indo!. On~litmus milk: slight acidity was noted. The strains were agglutinat'ed by: a known antiserum 'to the liinitof its titre.' Strailis which, ~atisfied the 'above tests' wel~e isolated 'froni'3 of, the 488 cases, iq 2 /las~s frOln thefooces,'in 1 from the urin,e. Of' l '.. ..",

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430 A B0ct~rio,logical\ Examination of Oonvalesc.ents .~ ~ " - , I I ' . ~ I .' ) ~ . '.

, 'these cases two had 'been diagnosed as enteric fever and one as, dysentery., " ' '

, \

, Qne yasewasexamined 3 times with 3 'positive results';one,case ,', was' examined 7 times w~th 3pdsitive results ;, '!ind one case was'

'exanlined 7 t}mes with 1 positiv~ result.' Seru'm was exan;ii~ed from' , ' , thes~ cases with the following res1}lt8 : One serum agglutinated' a,:1

" par~typhoid A' eniulsion in a ,dilution of1 in 100, the other two in dilptionsof lin 200andi in 400 respectively. ' /,' \,' " /

,B.,PARATYPHOSUS ·B.' \' , "-

Th'es,e strains fermented glucose and mann'ite but had no action on can,e sugar and lactos~.' In contradistinction to the strains of

, B .. pa'ratyphos,uJ; A, gas forniat~on was well marked on giucose and ,mannite. ~'i ,", "

" . ". I, '. '

. The bacilli were :tllotile, and did not produce indol. On litmus, milk ',slight acidity, 'was produced . which' was followed' by the development of an' alkaline reaction in two cases on ,the third ,day, ,and one on the eighth day. 'The strains' were agglutinated DY a: known antiserum to the limit of its ,titre; . ,

Strains whic,h sati'sfied the above tests were isolated £romthree of the 488 cases, in each -case from the J freces, ana each case had

• been diagnosed as enteric fever. ' . I \, '

- One case was examined 4 times "ith 4 positive resul,ts; one case was examined 6 times with' 2 positiye results; and one case, was ex;amined 4 times with 1 positive result. , ' , \

Serum was E)xamined from these cases with the' following results: On'e serum agglutinated B. paratyphosus B in dilution of 1 in 1,600, ,the other tWbin'dilutionsof l/in 800 and 1 in '400 respecti vel y. '

B. DYSENTERIiE(FLEXNER) AND RDYSENTERIJE Y (HISS

, 'AND RUS~ELL).

Twostraihs gave' the reactions of' the, typical Flexner-b~cillus. These strains, ;were non-motile,: produced acid but not- gas, .in glucose, maltose and J;llannite, produced indol and were agglu,tinated by a knownanti-Flexner serum. The serum of neither

, patient aggiutinated a stock B. dysentel'iaJ Y In' a 'dilution of] in, 50. The ,results obtained b{the examin~tion of one, of the~~ patients

" weresufflcientlyremarkable to hlStify separa~e mention. ' , This man(~.) ,was taken ill on, DeceQlber 21; at.SuvlaBay'

(he had previously been ~tLemnos).' He ,had had two inoculations

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H. De,an, R 4d~nison, ,J. Giles. 'and.B;. Williainson431'

. of,tykhoid vaccine,'in May' and June, 1915. ' He:was di,agnOsed as ' enteric fever. He was four' weeks at.the 19thStationaryH<;>sP!tal

. at ,Imbios 'and five weeks at the, 21st General,Hospitalat' AleX;ridria,. ' . , "', ," "

" " At ,th~titUe of'examiilation April to}uly;,.l916, he was quite' , : convalescent, there was rid ,diarrhooa. .Thefffices :were examined

\

, , ion seven oC,casion;s. :'The. Mac'Conkey plates. were usuaily covered .'. wit~pale' colon.ies." , . '" ",' ,

,The results of the, 'examinations were as follows;--.:.

-< .' Exa~inaUon

April 3

" 18

" 26:' ,May 11

'". 31 . June' r

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L.

" 21-, ~.'-. "

, . Result ' Flexner bacillus l'j 0 pathogenic b~cteria' Ybacillus Y bacillus" , Y bacillus and Flexner bacillus, Y biwillu8

'Y b'aciiius

, The ffficesof t:his patient'were found to contain two' strains~f dysentery' bacilli, 'the Ane of' ",hi6h '/erfuented .. maltose,whil~ the 'a,ther ,straindid,n:ot: ,Tlie agglutination reactions' of ,the' patient's serum ina dil-qtiqn' of 1 In QO were as follows;-'-

Typhoid . P~ratyphoid A" Paratyphoid B Ybacillus Shiga baCillus ++++0 . ++++ +++ ,0 ,<'

"On 'furtherex~mination the serum agglutinated, paratyphoid B in a dilution of 1 in 1,000, and bacillus·Y in a dilution' of 1- in 100 . .:Thf ser~rrl also aggl-qtinatedthe'y strain isolated f;omthe patient, but not the Flexner,strain isolated from, the patient. " ..... ,

.. ," F~om a!:iother ,case a~trainwas isolated which 'gave the cultural reactions' of ,~~ Flexnerb,acillus' but ,.'. wa~ not, agglutinated' by 'the 'stock antiserum . Thesm:um'pf this, patieht was :1,1nfort\lnately rio~., 'examined. ~ Tw()~trains"gave thfculti.uaLreactionsof the Y bacillus . but were not 'aggiutinated by thestoyk antiserum. , The,sera of'

", th~se 'two patients were exanijned~One; agglUtillatedthest()c~ strain of Y bacillhs:in adilutibn of ,'r in ~OO,. the other failed, 'to ,I produce aggf~tinaPion il} a dih,ltion of 1 in' 50,. \ .

" The result maybe summarized'as follows,:'......:. ". , . • . Thefffices were examined froIll488easesand the. Flexner bacillus.

: I was, isolated from ,two ca~esana the.y bacillus' from' two cases.' . From ,one case bbtli the Flexner and the Y type were' isolated.

"

"

,I , ~B.DYS:ENTERlJE(SIHGA).\ I This micro-organism grow~ somewhat slowly' on MacConkey

" ,plates,. and the colonies at the end of th~first twenty-four hours~." I . , '" ' , I '

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432 'A' T}ac terio logical -Examination Dj Oonvale§oe,rtts

al~ smaller' thanth;se of B.typhosu8. ," The strains isolated'ferment~d glucose 'but had no action on, cane sugar, lactose anamannite~

, They were non~motileand did not prodqce indol.... On litmu~ milk' sligpt acidity was· produced aftextwenty-four, hours. TJ;le acidity usuapy di~appeaied'after'thr(3e to seven days. ' Thestra,ins were

, agglutinated by a known antiserum .tothe limIt of its titre. ' The bacillus was isolated fronl the falces d six of the 488 cases;

Of the six patients ~'had been diagnosed as dysentery, 3 as enteric fever, andl as d'ysenteryand enteric. One case ·was examined

,3 times with ,2 positive results; one case was examined 7 times ,with 4 positive results ;/ one case was examined 4 times with 1 positive result; one case was examined 3 times with 1 positiv$ result; two, cases:were examined-6 £im~s with 1 positive result. Serum 'was, obtained from 'each of t,hese six cases and ,three (lompi~telyagglu-, tinated an emulsion of' Shiga bacilli in a- dilution of. 1 in 50, and

, three failed to produce agglutination~ ,Of these 'three ,sera, one had ',a tit:re of ). in 400 and' two of 1 in 200. .- "

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,The' following 9:.ccount gives some details of various strai~s isolated iro~ the falces which produced pale colonies on the ¥acConkey plates.' :' ,

, " Paratyphoid, G:"01tP~

" A Ja~g,e number of strains were Isolated which presented cultural characteristics, resem bling those' of th~, know~ paratyphoid bacilli.

, ,.STRAINS iyinCH, PRODUCED INDOL •.

: ....

:: "'These U;icro-organi~ms.ferm~nted g1ucose and l~annite and did , not ferment iactose and cane sugar. They produced 'indo!. , The, 'majority produced'much more g~s than, paratyphoid 'Bin glucose' , and mannite,. but two strains produced, no gas in' mannite and one ,~ no ;gas' in glucose. None of these strains liquefied gelatine. ',~ Strains: presenting the~e general characteristics were isolated from seventy

'seven patients. In' one case a \strain of this type 'was isolated on' three occasions from the fieces of the same patient, on six.occasions ' tyvice, 'in the majority of occasions only once. These strains can bediyidedinto, three groups according to their action on litmus m~ , , "

G1:0UP' A.-Thirteen strains 'producedno perman~nt change'on litmus milk. In three' cases slight acidity Which s;ubsequently -disappeared was observed after twenty-four hours incubation. ,

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"

. H., l!ean, B., A damson, , J. -Gile;\a~~d ~ R.willia~son 433 - \ ' . \

< Group B.-,-Tenstrains 'produced definite permanent acidIty;"

In four cases a clot' was formed. ,'., ' . Group' C.-Fifty-four . strains' produced adefiriite alkaline. re

"action, Of£hese nine showed. an acid' reaction "at the'end of, t~enty-four hOUl:S. " . '_ . , .' ,

Of these 77 strains\rw~re submitted to" anagghitination test. " with the patients' seruin. Qf th€\se' 9 straihs 4 showed slight" agglutination with ,the patients' serum in dilutions of1 i~25 and 1 in 50. ,In. no c'ase was agglutination complEite even in a dilution'

, of, lin 25· oC serum, and. we" are npt inclined' to' attach any Isignificance :to,the reslJItsobtained." ~Bacilli which resemljle !n cultural' characteristics ,the paratyphoid bacilli 'except that they produce' ind01, occur in norma'! freces;'and are ~ell kiiown to all bacteriologists. '.-'

I " > _. •

STRAINS . WHICH DID ' NOT' PRODUCE INDOL.

, Strai~s .cl~selY 1'esembling Paraty~hoid ,A.'

. Four str~inswill be c~nsidered under this h:eading:. ,-(1) This strain: was isolated ftom a soldier (M.) who' was tak'en·

, ' ill on October 28, 19l5; a~,Cape ReHes, where ~e had been statiolled after ,June 13. , The' illness 'was diagnosed as enteric£ever, and·,

, fasted SIX weeks. ~He was removed to a hospital in Malta.' He had had two doses ,of typhoid vaccine." At the time'- of the bacterio~ .

. .1og~cal examiqation he\yasiil'petfectlY..:good health a.n~ condition., At the firstexamin~.tionafewpalecolonies were observec} on the

. MacConkey 'plates:, ',The strain ifjolated: was a' Gram negative, non"' nl0tile bacillus resembling in'its morphology and cultural character~ ,

J istics on 8Jgar the inembers~of the:·B. coli--.:.B. typhosus group. "The . bacill~sfermented glucose: and' mannite ~hut not, lactose and cane,,'·

'. sugar. 'In mii~ slight acidity was ;.produced without clot, in broth there' was no indol 'fermentati9ri. Whe~' fhstisolated no gas was formed in glucose :andmamlite. After subculture in the laJ:>oratory the strain acquired the property of gasfQrmatlon In these niedia. The patient's sel'umin' a dilution ,of "1 in 50 producedqomplete aggluti~ationof B. tyjJhosus ang, B~paraiyp7iosus A~' An emulsion of B. pamtyphosJ-lsB ~asdistinytly but nQt completely agglu-

_ tinated.Th!3 ,ser~m'agglutinatea. neither Shiga nor'~'Flexner strains.,'

'The ,bacillus' -Was agglutinated shortly a~ter ~8ola~ion'by oUI anti:.paratyphoid A serpm in a dilution 9f1 in' 200 but not in greater dilution. ·.since~his ,serum produces marked agglutination, with paratyphoid A ,emulsions in a dilution of 1 in 50,000, the result: did

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. ' ,434, A ,Bacteriological- Exar?iinatio~ ,of Oo?"-val~sc~nts,,,

, n~t ' appear "of importa~ce.,We considered t?e bacill~s a, non-', ' J agghitinable paratyphoid A- and made a report to that effeCt. !Sub~

sequently we carried mH: a long series of observations with this strain, the res~lts of which are here summarized. , 1n a comp!e-"

. " I, • "

. ment fixation experiment )Ve used e ... xtra~ts' of the strain ,M and of our stock ,paratyphoid A strains and anti-paratyphoid A serum. With the M,extra~t the antiserum gave a strong reaction in a

\ dIlution of 1 in 100an'd traces' in a dilution of 1 in 400/,Witli the kno'wn, 'paratyphoid A extract a complete reaction was obtainEld with a serum dilution of, 1 in 1,600. An absorption experiment.,

" s~owed that Itn emulsion of bacillus M failed to relflove the agghl- \ tinins for paratyphoid' A fromanti-paratyppoid A serum. ,It should be m,enti6ned tha:t'the bacillils was"notagghitinated byanti,typhoid serum; Subsequently we immunized l:jJ rabbit 'against this <str~in. The S~rulp agglutinated emulsions pf bacillus M in a (jilution, of 1 in 6;400 butfaile<l to agglutinate pa,ratyphoid.A in' a, dilution,

',of 1 in 50.,' Meanwhile thestrailf M had "been subcgltured uaily ;for abOut a month and 'at the end of this period anaggJuti.t;la; , "tion experipient was performed. 'The anti·paratyphoid A serum ' ,produced ,complete agglutination of a known paratyphoid A strain' in a dilution of i jn 64,000, of' the M strain in a dilution of 1 in . 640.: That is to. say the result of subculture had, been to gEeatIy increase 'the agglutinability 'of ,the sfrainM 'with paratyphoiii A seru~. Th,e<agglutinability howe'ver; Jell, far sh9r~' 'of .that '6~ ,a: ' '~nownstrain of paratyphoidA. ' An,emulsion)n sai'ine solution was not pathogenic foritheguinea-pig. 'Our experiments with this' strain are still beiIig.co~tinued:' " , '(2) The patient (G.) had had two typhoid in9cula1(ion~.He ,'"

• ,landed at 0ap13 Helles from Devonporton October 22 and remained ," in good health until the firf';t we,ek in Dec~mber. Di.ning the early' part of December he ,suffered from diarrhooa and headache, was

, treated at a field ambulance on Dec~mber 18 and adm:itte(l to a base hospital on the beach a few days late'r. ' Arrived in Alexandria on, '

,,December 26" The diagnosis was enteric /fever. He was at' a~' 'hospital at Cairo for· five weeks and for four weeks in a convalescent camp, . " " ,

At 'the ti~e 'of ,exam:ination he '\yascomplelely 'conv;1lescent, ,The,ba~illus isolated from thefreces resemble,d in, morphologic~l . i

and culturareharacteristic.s the members ,the B. coli---,B~, typhosus ,group. 'It was not motile. Glucose andm:~nnite were ferD;lented -,with formation of acid but not gas, ,but lactose and cane sugaE were not~ Litmus milk was slightly acid after twenty-four hours incu~

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H. Dean, R. Adamson,J. Giles and R . . Williamson 435

oat ion hut ,appeared . to become n'eutraConthe second day. No alkaliformationwas observed. .Indol was not formed., 'After subculture,\hisstrairi acquired th~:property of produping_gas in glucose andmannite peptone water: "Whenfirst· isolated.the

, , bacillus was not agglutinated by either' anti-typhoid or .anti-para- '. typhOid A serum. in ,a dilution r in 100. " Both these se~a agglutin-' atedt.heir homologQus str~ins in a'dilution of.1,in 50,000:, Three months afterisoll1tion the bacillus was agglutinated equallY well

~ by both ,anti-paratyphoid A and , anti-parll,typhoid Bs.erurn in _ dilutions of 1 in 160. ' . ' , , 'rhe pati~nt's own serum ina dilution of 1 in '50 agglutinated

"erimlsions of typhoid and, paratiphoidB i~completely, and of 'paratyph6idA not at ale On the other hand,the patient's ser],lm agglutinat~d his own baeillilscompletely in a dilution of 1 in 400, and ~oa slightcexte11t in a dilution of. 1in 800i , ,": ,.',

" In a subsequen~ experiment it was sbowa that the serum: 6fthis patient agglutinated his own strain, and' that o'fthe patient M: in a' dilution of 1 in 800, and the strain isolated from' the patient Vi, in a'dilution -of 1 in(200. This strain W\1S not pathogenic for the'

'. guinea-pig. " , (3) The patient (W:) had 'bad twci 'typhoid 'inoculations., He

arrived at Suvla ,Bay on August 8, 1915. He' was taimn ill in September, arid removed to the3rd Australian Hospital at Lemnos. The, illness lasted for ten weeks, an{l "the clinical diagnbsis was

, enteric fever. He was admitted to Hope Hospital on December 5. '':'' At the ,time of ex~mination he was in good health.' The bacillus~

• F .". . ,-' ,'., " was Isolated on on~ occasIOn only; and had the follOWIng charac-teristics. It resembled in shape and staining reactions the R coli~ B. typhOSllS group. It ,,'as actively motile. Itproduced,acid and a' trace of gas in glucose and mannite, , It bad, no action on }:~al!e sugar and"lactof1e.; It did ,not produce indol and it did nbt'liquefy gelatin. It, prod~,ced a' slight acidi,ty without, Clot iIi milk.

, : Immediately,- after: isolation an emulsion of this'bacillus was put , up, with anti-paratyphoid A, imti~paratyphoid B,and anti-Gaertner

sera in dilutionsdf l'in 100, Noagglutinatioi1 was observed, , About itWO, months later the bacillus wa~ agglutinat~dby~: low

dilution of anti-paratyphoid A serum, but not by anti-paratyph6i,d B , • serum. A1rabbitwas immunized against this strain, and theserul1l

so obtained agglutinated its own bacillus ina dillitioD: 0(1 in 6,000. This :'serum 'agglutinated an emulsion of 'E. paratyphosusB. ina , dilution of 1 in 200, but failed to agglutinate' E, 'paratyphosus A.. in

I a dilut'ion of 1 in 2,5. The serum of this patient was not obtained, 30 ' ' ,

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~36 A J3acte1'iQJogical Examination of' Convalescents,

, as he was i:emoved from Hope Hospitalbefore our examination had ' been finished. This stmin was not pathogenic for the guinea-pig. '

(4) ,The' patient (R.) had had two typhoid inoculations.' HE( arrived in F;gypt in March, 1915, andwas transferred to' Lemuos

, in August. 0)1 August 15 he was taken ill, admitted to the l,8tli Stationary ~ospitM, and diagnosed as ent~ric Jever. 'The illness lasted three' weeks:; Anhetime, of examination the patient was iu

, good heal~h. " ,_ , , . . _ ,. The hacillus isolated from R. was a motile bacillus with the' - .' - , .' .. - - .' -.

general cultural and ~orphological characteristics of tbis group of bacteria. It did not liquefy gelatine. It produced acid aI!d gas in 'glucose and mannite. Itdid not ferment cane sugar and lactQse~' It did not form indol. Sligllt aciditywitbbut clQtw:ts produced in' litmw," milk. ,An:ti~paratyphoid A andanti-paratyphoiq B sera in

. dilutions of 1 in 50 failed to agglutinate this bacillus.Emul~ionE! of the bacillus failed to remove, agglutinins for paratyphoid A from anti-paratyphoid,A' s~rum. ( The patient's serum was not examined. A, ,rabbit was immunized,: but the serum wh'ile agglutinating, the homologous bacillUS ina dilution of 1 in 6,400 failed to agglutiuate emulsions of paratyphoid A, paratyphoid B, and emulsions of bacilli isolated from M, G,and VV. This strain was not. patbog~l!iic .

. for the guinea-pig. . , ' . . We,. have carried Qut, a rather extensive series of eiperimerits .

with the above four strains (M, G, VV, and R), and hesitate at the, :present moment to 'express a definite opinion. The strains show a

. tendency . to be modified in their characteristics 'as ,regards gas forJIlation andlJ,gglutinability as' a result cif . repeated subC;ultur~. Our, investigations are being continued, and we are inclined to think that the strains M', G, and W, are closely related, are members of' theparaityphoid;group; and 'are dis,tinct from either paratyphoid A, or If The straih R is probably a different variety: " " \

BACTERIA RESEMBLING B. PARATYPHOSUS B •

. (1) The patient (B.)-had had tw~ typhoid inoculations. He was . taken ill on 0ctober 31, 1915. The illness lasted for about a week, and was accompanied, by diarrhooa and the passage of blood in 'the. motions." . " This bacillus was a non-motile bacillus presenting the general

, characteristics common to the B. typhosus,~B:coli group. It pro- ' .ducedacid and gas in, glucose and mannite.On iitmus milkthe

, reaction was at' first acid, but became aU{lUine after tl'lndays. It

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. . H-; Dean, R.· Adamsoh, J." Giles and R. Williamson' 437

(

did not produce indol, .and it did not liqu'efy gelatine. It was'riot agglutinated by anti-paratyphoid A, anti-paratyphoid B,- or anti~ Gaertner ,serum. ' '.. ..... .' .

(2) '11he patient (E.) bad had tw~ typhoidinocu)~tions., Hec6ntracted dysentery at Suvl~Bay,and .was sent to t1Je21st General'

, Hospital at Ale~dmdria; He contracted enteric fElVer on board ship ,on his way back ,to England. .

i' . This bacillus ,was isolated on four occasions from the fruces of thepatlent~ ,it' was a motile baciilus with the general charac'teristicsof 'the 'paratyphoid group. Glucose and mannite were fermented with' production of ~cid and gas. Cane sugar and lactose were no.t fermented. Milk was acidified' in twenty~four hours and became alkaline on tne, third day. 'No' indol was produced and gelatIne was riot liquefied .. Anti~paratyphojd A, anti-paratyphoi(1,B and anti~.Gaertner'serum failed to agglutinate

, an,emulsi~nof .this ~adlhis. , The serum of the patient failed to / agglutinat-e ,this strain but aggl)ltinatedin lQw dilution, (1 in 5.0 to

1 in: 200)' emulsions of both 12aratyphoid A and paratyphoid B.' A rabbit was injE:)ct~d withefuulsions ofthisbacillus. The' resulting serum failed .to!~gglutinate the homologous strain; This .~ti:ain was not pathogE:)hic ·£orthe, guinea~pig. " .,. , ....' -,

T~ese two 'strains exhibit~d a similarity in cultural1;eacti6ns to , 'members oqhe B. parat'ypho'sus. B group." , ,', , . ',.. 'Serum reactions entirely failed :to ,establish any relationship

between these,strains an'a typical strains of the paratyphoid group •. ,In addition- to the above bacteria we isolated ,one strain which

, . fermented glucos~andmannite with a?id and gas' production, was HlOtile, produced an' alkaline reaction in m!lk and did not, produce in'dol., This bacillus ,liquefied gelatine in about ten days and its

\" investigation was' discoi1tinu~d:' " ',' • " • : - ~ , • • I

OTHER B~CILLl WRICH DiD NOT FERMENT LAC;.rOSE. , I .

" In the course of oriryVork we)solated and, examined a' la~ge number of strain~ which appeared as pale .colonies on MacConkey • prates~ ,The majority are, no <doubt,of, little interest to' the pathologist. We; were, however, impressed by the fact that in a few cases the piates of some particular patient were, on each occasion covered ~ith pale' colonies, and On eac~ occasion the !;lame

, baciUuswas obtai)red in pure culture .. , J.: ' /

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438 ,A' Bacteriological Exam~nation of CO'nvaleicents

STRAINS HAVING~NO ACTION ON GLUCOSE; CANE SUGAR,'

MAN'NITE AND LACTOSE.

'(1) Twenty-one strains showing the above reactions produced ' a definite alkaline reaction °in 'milk. Indol was not' f.ormed and gelati~e ~as not liquefied. ' TheRe are the reactions of B. fcecalis;

, alkaligenes. . (2) Two strains. produced no chang'e in litmus milk.· Neither

fornied indoL ' , , ./ , (3) One strain produced no change in litmus milk, but formed

indol. . Serum w!1s obtained in three cases, but in no case was ·agglu-.

tiuationobserved with the bacillus isolated .from ~he patient. . I'

STRAINSPROD'UCING ACID BU'f NO'f. GAS ,IN GLUCOSE. , " -

One strain wa~ is~l~ted which fornied i~dol. The nlilk culture wa~slightlyacid after twenty-four hours, after three days it becam~

, neutral/ . Gelatine was liquefied in three weeks.

S'rRAINS PRODUCING ACID AND GAS IN Gr;UCOSE.

Thir.teen strains fer,mentedglucosewith acid ~nd gas production· but had'llo action on cane sugar, 'manpite and lactose. Indol was produced. ' The. reaction in milk differed slightly. In nine 'uo' . change was observed, in three an alkaline, in one an acid reaction, developed. From one patiel!t a strain of thIS type was isolat(:ld on five occasions, fro'~ two on two, from the rell;J.ainder on oDe occasion ' .only. ,The plates of the. patient from whom the baGillu~was isolated on five occasions ,were always covered with pale colonies,

, all of which were presumably of this variety. The serum 'of this patient agglutinated an emulsion of this strain in a diltitic)ll of 1 in 200. Serum was obtained from fo~r other patitmts. but' the agglutination'reaction gave a negative re.sult. .

These strains appeared to be· of some interest as the bacilii isolated closely resembledMorgan;s~o. 1 bacillus. We accordingly prepared an antisetuni by'injecting a rabbit with a culture of, Morgan's bacillus. The' serum from thisanimar agglutinated an emulsion of Mo'rgan's bacillus in~ a dilution'of 1 in 3,200, but. only one 6fthe stniin.s. isolated f~om oUF series of patients.,

We ne~t prepared "an antiserum by InjeCting a rabbit with the strainB isolated from the patien.t who had produced, a bacillus

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,,' H. Dean,R. Ada1nso1J, J. Giles, and R. Williamson', 439

·ofthis, type on five separate oc.casions. This serum agglutinated an, emulsion' of Morg~n'sNo. Ibitcillus in a dilution of 1 in 600 imd two of the. strf!,ins which produced an ;alkaline reaction on milk were equally well agglutinated. The other str~ins, including that yvitll which the rabbit had been immunize,d, were notaggllitinated. These results are obviously not entirely satisfactory, but the case of the patient-B.; who produced a bacillu8 of tpis 'type on five separate occasions, appears to be ofsome)nterest. .. '

t)TRAINS FERMENTINC GLUCOSE, MARNITE AND CAN.E, SUGAR.

A considerable:'~uniberof bacilli were isolated which fer~ented the~e three s~gars: Of thE(senine strains were isolated ~hich 'fer-

, ment~d glucose"mannite and cane sugar with the p'roduction of acid 'Only b,ut not gas .. No reactIon took place in lactose. 'In litmus milk the strains. showed some variation, in three cases an alkaline r~action occurred,intnree the meaium was rendered slightly acid; in the remaining.cases· no reaction' occurred .in' milk.' In broth indolwas produced in all except one strain. In one case a strain of, thi~ type wa~ isolated on three occl1sions, and in another, case it· wa,s isolated twice. ' Emulsions oC four of these strainswer~ tested with serum from, the patients,but no agglutination tookplace in-a serum dilu~ion of 1 in 1)0.' Strains fermenting glucose, manni,te" and cane sugar with the production of acid and gas were isolated in tw'enty-fiye case.s. Frolll, one patient an organism ,of this type was isolated on four occasions.' The plates in this case were often covered

~. with pale colonies, presumably all similar, and were apparently free from lactose fermenting organisms. In one case the organism was isolated three tin;les, and from another patient on two occasions. The reaction of. nineteen strains in litmus milk was alkaline, of six

,it was either acid or neutral. Two' of the twenty-five failed to give " an indolreaction. Em~lsi(jn~ of six,strains were tested against the patient's sera' i In one Ci;LS~ agglutination was observed in a dilution

,-of 1 in 50, in one of 1 in 100.' The strain which was isolated from the same man o~ four occasions was not agglutinated by the patient's

- ' ~ . '. . own serum.

LATE LACTOSE FERMENTERS. , , '

All the following strains appeared as pale colonies on MacConkey plates:-, " " ,

(1) Thisstraip, fermented glucose and mannite, producing acid, . but not gas. An acid reaction developed in lactose pepton~ water

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440 ,A Bacteriological Examination ofOonvalescents' .. after five to seven days'jncubation, but cane sugar was n~t fer~ented., ' Litmus milk becameall\:aline after preliminary acidity. The organism f()rmed indol but, did not liquefy- gelatine. The bacillus ,was not motile. It was isolated 'on' four oc~asionsfrom ,thes'ame case, but' was not agglutinat~a: by ~he patient's own serum. ': " " .. (2) Two strains ware isolated which produced acid but n9t 'gas

on glucose and cane sugar. Lactose was fermented by one strain' after twenty-four hours, by the other strain after five ,days ; mannite, was not fermented. In litmus milk there was no change, ,in broth no indo!. Gelatine was not liquefied. One of the strains was tested with the' patient's own serum, but no ,'agglutination was, observed. ".

, (3) Two stralps were isolated which produc'ed acid but not gas , in glucose and laoctose,and two strains~ whi'ch' produced both, acid ,

, , .' " ('" -and gas. In other resp~cts these four strains resembled one another. " ~ eitber cane sugar nor mannite 'Yere fermented.' Milk ~as clotted with an acid r,eaction and indolwas produced. '

(4), Ten strains'produced acid but not gas in glucose, cane sugar, man,niteandlactose, in milk acid and clot, in broth indo!. ' One strain ·was Isolated which produced an alkaline reaction in milk, but agr~ed III its other reactions with the· above ten strains.

BLOOD CULTU~E.

Blood cultures were made from seven of the carriers. About ten' bubi~ ceritimetres of blood was taken and mixed with 100 cubic' centimetres of broth.' Plates were prepared' after various intervals (up to six days) of incubation. The blood proved sterile .in the Case of six patients, who were in good heaIthat the time of . €xamination. One n1an, a paratyphoid carrier, was suffering from ~n acute illness; which was thought incorrectly to be a relapse, at\ the time of ,the examination. The streptococcus mUCOSlM was isolated from the blood.

AGGL UTINATION RESULTS.

,We employed the usual and well-known macroscopic method ,(see Section on Methods). The resuits were read after twepty-four hours, and have been expressed 9nthe table by the pumerals 4, 3, 2, andl. A complete reaction in which all the bacilli ~ere

, precipitated in a firm 'niass leaving an absolutely clear snpernatant .fluid is expre~sedas 4. If the supern'atant fluid was slightlyopalescent the result is expressed .11S 3. A moderate deposit of agglu-

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,H. Dean, R'. Adal1is~m"J. Giiesi and R. WiUiamson 441

tinated bacteria with' turbid s~pernatfmt fluid 'is expressed' as 2.! A small but quite definite dt)posit is expressed as 1. ' In: e,-:ery case a 1 in 25 dilution 'of the serum was mixed with atl" equal volume '

, bf' the, bacterial emul~jon. Th; totaldiluticin of the serum was" therefore 1 in 50.,' The results obtained in experiments such as these depe~d 'greatly on the characteristics" 6f the particular, strain'

, of 'bacilh:is'which'is used'. 'In the case bf our paratyphoid Band' Bacillus Y strains we are riot inclined 'toat,tach any importance to , a less degree ,of agglutin'atlon th~n3.' ~a;hestrains ',of typhoid, paratyphoid A, and Shi'ga showed no ten'dericy to 'agglutinate with normal serum,. "" '

TyP,"H;,OID., , , " l " ..

',The date of inoculation in all cases inwhi6h it was ascertained is given in the table. Practically all,thepatients 'had been inoculated; The'agglutinins observed were probably the result of inoculation.· JI;l no case was' B. typhosus isolated from, the f~ces. Of ,322 cases 170 gave a complete reaction, 60' an aimost complete 'reaction,25gave:a marked reaction, and 7 a slight reaction.' Of the 322; -3 only ~re known not to have been' inoculated. In 24 cases 'the infbrmation :was' not Cobtained. That iSI:to say, of 295

, cases k.nown toha~e been inoculated 23.failed in the agglutinatIon test, while 230 gave .8. complete, or almost, complete reaction in a dilution of 1 in'50. ,Our examination was carried out in March and

, ' ~

April, 1916. '

PARATYPHOID A.

In the following summary 'of /the results obtained by the eX8!m-, ination Of patients' serum, we have left'out of account four cases

which donotbelong',to the series, and in which the !?er-gm was examin~d after th~ isolation of a pat~(jgeni9,bacillusfromt~efffices; The summary, is !based, on the, results of an examination of, 317 unselected conval~scents of whom 130 had been diagnosed as dysentery, 171 as! enteric, while 16 were said to have had both enteric, fever and dysentery. , ' , '

Of the, 171 enteric convalescents, the reaction' was, complete in 13, 'almost colllplete in 4, well marked in 1. Of , the ,130 dysentery cases; almost complete' inl and well marked in 1." Of 16, cases dIagnosed as dysentery and 'enteric th'ereactionwas well marked in 1. 'rhe approximate :tipre of 14 of these ,sera was determined:-'- ' ,

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M2A Bacteriological Examination of Oonvalescents

The titre was 1 in 1,600 in 1 case, , 1 800 " 2 'cases

1 200',,7 " '- _ ',,' 1" - 100" 2 "

" " . 1" 50". 2' "

Several of these sera also r,!:lacted with paratyphoid B emulsions; The incidence of paratyphoid A infections as judged by agglutina~ tion results, including the 18 eases 'only in which the reaction ,in a

, serum dilution of 1 in 50 was complete 01' almost coniplete, was 10 per cent for enteric convalescents, 0'7 per cent for dysentery' con-valescents or 5'6 per cent'-for all convalesCeiits. '

. PARATYPHOID B. Of-I71 enteric conva,lescents·the reaction was complete iI1 '24, .

almost complete in 36, well marked in 36, and slight but"definite In:, 9. Of the~ 131 aysenJery convalescents the reaction was com~ pletein 9, almost, complete 'in 10, well marked in 4, and slight but definite in 1. Of 16 dysentery and enteric convalescents the 1'e- x

action was complete in 2, almost complete in 3, and wen marked' in.4:, The strain of B. paratyphosus B which we employed had a tendEmcy to show a slight degree of non-specific agglutinationwith normal sera In low dilution. We have accordingly excluded' all cases in -,which anything less than an almost complete reaction was obtained in a serum dilution of 1 iri 50. The reaction was complete or almost complete in 84 cl1ses.· We made . a second examination of 51 of these sera'with the tollowing results :-'-

The, titre was :( in 1,600 in 10 cases

". - ".'.' 1 "

800 "

7 "

" " 1

" 400

" 9 ".

" 1

" 200

" 12

" )

" ", 1 "

100 " 13 ,;

The incidence of parl1typhoid 13iI1fection as estimated by the agglutiriation reaction was 35 per cent for enteric, 14'5 per centior dysentery and,31'2 per cent for dysentery and enteric convalescents, or 26'4 per cent for all convalescents. -

It seemed possible that sorn'e of, the cases of enteritis might 'have ,been caused by bacteria ·belonging to the B. enteritidis, (Gaertner) group. Seventy-three sera w~retested with an emulsion of B. eMeritidis. Of these three gave a marked reaction .arid thrE;le a slightreaction in a dilution of 1 ,in 50 .. Of these six sera five 1'ea.cted, far' more strongly with B. paratyphosus Band' the resuWobtained was regarded asa group reaction. The sixth serum was o~~ of the three which gave a veryslight reaction. "

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H. Dean, R. ~Adamson, J. Giles-, and E., Williamson 443

B. DYSENTERIlE (IhExNERTYPE). ' "

,The results of experiments carried, out with a'la:rge number of sera were discarded as' tpe particular strain of Flexner bacillus

, which. we u~ed PJoved to be quite u:r;lsuitable for the purpose. Emulsions o(this bacillus were iit fact readily agglutinated by normal serum in a dilution of-l in 50. :The following :resu1ts were ob,tained with a strain of the Y type: ',The total number of sera' , tested with this strain was :190. Of 170 enteric cases the reaction

'was completeiQ ,l,alinostcomplete in 7"well marked in 11, and , slight, bu,t, definite in 9. Of7 dysentery eases' the reaction was , almost qomplete ':in 2, and well marked in 2. Of 13 -dysentery and , ent~ric cases the'~eactlon was complete in 1, 'and well marked in 1. "

.. Four of these sera were suhmitted to fIJrtherexariliD!1tion:-'-: ' '

, ' ,The tItre '~as 1 in 2GO in 1 case

" " '

" "

1 " ).00 " 2 'cases '1" 50" 1 case

,Excluding all case~ exc~pt ,those' inwhi~hthe reaction was complete. or almo~t complet~we arrive at a percentage of 4'7 for

" the' enteric' cases. ' , Unfortunately the number of dysentery cases' ,examin,ed 'with the' satisfactory strain of Y bacillus ,,,,as too, small to allow of any definite conclusions. '

l? DYSEN:r'ERllE(SHIGA TYPE).

The tot~l number of sera eX,amined ,Was' 31~. Of 171 Gases , diagnosed as ellteric fever the reaction in a serum dil]ltion of 1 in 50 was c'omplete in!, almost complete in 1, and well marked in2. Of 132 c.\1ses dif!.gnosed as dysentery the reaction was complete in 4" almost completein2, well marked in], and slight but definite in 1. Of}6 cases diagn~sed as dysentery aIld ent~ric the reaction was almost complete in 1. ,", ' , ,

Seven,of these sera were submitted to further examination :~

Tp.e titr~ was 1 in 200 i~ 1 case ,,' '\ 1 " 100 " I' ,;, " 1" 50" 5 cases

The Shiga str~in which we employed~ was free from any, tendency to non-specific agglutination and we include all of the few cases which gave' a reaction: in a serum dilution of 1 in· 50. ' The incidence ofShig~ infection as judged ,by the agglutination reaction" was 2'3 per 'cent, for enteric convalescents and 6 per cent for dysentery convale~cents, 'or 4 per cent for all cases.

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444 A Bacteriological Examination afOonvalescents

DYSENTERY CASES.

" ,

AGGLUTINATION" RESULTS :l ' "', -.0 '0 S ' .0 '"

~ < g Po" ;l', ~ 0>00 el el .".;.._. ;g Bactei:ia' and protozoa' i. ..... "ol Date of typhoid '" ,C ] :\~-"" '" 0- inoculatioilS "" ,"" §; -'" ',foUl)d ' " ~ ~-<j ~~ """ "0 '" "

"'0 ~I'Q ~'-~.o " .0" ] ~ 1; '" ~~ 2' s· .... <: " " " ~~ - "" "" 1'4 1'4 -'0-'< Z ~ ~ 1'4 -"" .' , ,

"

,2 2 - 0 0 0 0 -3 2 February, 1915 .. 0 -0 6 - 0 - , 4 2 ,- 2 0 0 - 0 , Lamblia t'ntestinalis. 5 2 Aug. - and, Sept., i914 3 0 0 -, 4 -6 2, ' December, 1914 3 0 0 - 0

, -I 9 I 2 May, 1915 ' :. - .. 4 0 3 - 0 Coccidian cysts.

10 2, - -3 0 0 ~ 0 Trichomonas.

,-

11 -- - 4 0- 0 - 0 -12 2 - 2 0' '0 -, !) Entammba 'coli, Macro-

stoma. 13 2 3 0 3 0 L. intes'tinalis;' '-' - '-' -14 ,2 - 3 0 0-, -, 0 -15 2 - ,4 - 0' -- 0 -16 I 2 - 4 -- .4 0 Coccidian cysts. ~ 17' 2 - 1 - - - '1 -18 2 - 2 0 0 - 0 19 2 - 4 0 I 0 - 0 -20 2 ,- 3 0 0 - 0 -21 2 - 3 0' 0 - 0 -22 2 -- 3 0 0 - 0 -23 '. 2 April,,1915 .. .. 4 0 0 - 0 Cercomona's~ , 24 2 - 1 0 0 - 0 --25 - 11 - 3 0 0 - 0 ---26 2 - 4 0 0 - 0 -27 " 2 - 0 0 0 - 0 - " -28 2 - I 4 -0 0 - 0 -30 2 - 4, 0 -0 - 0 ~. intestinalis. 31 -2 - 4 0 0 - 0 -32 .' 2 - ,'4 '0 0 - 4 -33 2' - 4- 0 0 2 -

.-' 34 2 - 0 0 0 I

- 0 ,t. intestinalis. 35 2 August, 1915 .. .. 4 0 0 0 0

" " 36, 2 - 3 0 0 , - 0 -37 2 - 4 0 0 - 0 L. intesanalis. 38 2 - 4 0 0 - 0 - -,39 2 - 0 0 0 - 0 Bacillus dysenteri

(Flexnerl, L. intesti naZis.

40 2 ,- 0, 0 0 - 0- Macrostoma. 41 2 -- I 0 0 - 0 -42 2 - 4 '0 0 - 0 L. intestinalis. 43 2 -- 4 0 0 - 0 E,- histolytica. 44 2 , -- 0 0 0 - 0 L. intestinalis. 47 2 March, 1915 .. .. 3 0 0 - --0' -49 2 - 4 0- 0 - 0 L. intestinal~s; 50 2

",

4 0 0 3 -- , -'51 2 - 1 ' b 0' - 0 -

,

54 2 - 0 0 0 - 0 " -

55 2 - 3 0 0 - 0 L. intestinalis. 56 2 - . - 0 0 4 - 0 -

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H. Dean,' R.Adamson, J. Giles"andB. Williamson 445

'DYSENTERY CA.,Es-coii,tinuea.' - " -.. '

AGGLUTINATION: RESULTS. -~ ~=s

' ,

.0 'S "'''' ..

" "''' ~ " ~ ~ ;.,0' .§ , , '

" !~~ ;g I:l

l>: Date of typhoid. '" ~. ~ , '~. '-~ Bacteria,and protozoa'

.8 1 ~'g { inoculations o~ § "'- ~ . i.~-· :' found ~ - i '" . ~~ • os

.0" .~ , ,.,<1 .~;:q .~@. ~E: '- '" ,.0 S·- '. .~ " " ",,'

os .::;::.

~. '" '" ,Ri Ri .:l z .Ri I ,Ri"

, . , " .. ,

"

57, 2 J - 4 0 0' - 0 L. 'intestinalis. 58 ,2 .. 2 ,0 ,,0. - 0 - .'

J ' . 59 ? ~ ,3 4 " 0' - P

,60 2 - 4 0 0 - 0 61 2 - , ,3 0 0 - 0 E. coli. 62 , 2 J.lme, 1915 .. .. .0 0 ,g - 0 '! ...-64 2 February, 191~ .. 4 0, -- . 0 -65 i! July, 1915 .. .; 4 0 0 - 0 -66 2 Deceniber;1914 .. 4 0 0 - 0 L. intestinalis; 45 2 - 0 0 0',

" - 0 " " 67 1 ' July, 1915 -- .. 4 0 0 - 0 " .", ,-

68 2 May and August,,1915 4 0 0 - 0 E. histolytica, Macro-stoma. , c, "

70 2. Ap,ril, 1915 .. .. 4 0' 0 - 0 E, histolytica, L. infes-I " tinalis. I

'71 2 September, 1915', .'. 3 0 4 - ,0 -72 2 August, 1915 ' .. l· .. 4 0 0 - 0 -73 2 May, 1915 .. .. 4 0 0 - 0, E. coli. '

,74 2 Aug. and Sept., 1~14 .. 4 '0 1, -' 0, -,-

75 1 September, 1915 .. 4 0 0 - 3 -76 2 May, 1915 ' .. .. - 0 0 0 - 4 B. aysente~i(JJ (Shiga): 78 2, December, 1914, .. 4 '0 0 - 0 -79 2 July, 1914 , .. .. 2 0 0 - 0 E. coli, Macrostoma. 80 3 2 in December, 1914 ; 0 0 3 - 0' -

1 in August, ;915 81 2 June, ,1915 .. .. 4' 0 2 ~ 4 -82 2' July and Nov., 1914 .. 2 0 0 -, 0 L.' iritestinalis. 83 1 August, 1915 .. f .. 4 0 4 - 0 E. histolytica. 84 2 August, 1915 . .. .. 4 0 3 ,~ 0 -85 2 July and Augt!st, 1915 4 0 0 - 0 E. coli. ,

,86 2 August~ 1914 .. .. 4 0 0 - 0, E . .. histolytiCa. 87 2 April,1915 .. .. 4 0 0 ... - 0 -, 94, 2 July, 1915 .. .. 0 0 0 ~ 0 -.. 95 0 - ·0 0 0 - 0 97 2 November, 1914 ~ -. 4 0' 0 0 -.. - ,

• I

98 2 Oct., 1914;, Aug.;: 1915 4 0 4 - 0 -,

99 2 March,1915 .. ,' •• 0 0 3 - 0 -10'0 2 -January, 1915 .. : ;. 2 0 0 - 0 -, 101 , 3 May and July, 1915 .. 4 0 3 - 0' -,.

102 2 September, 1914 : .. 4 0' 4 - 0 -108 2" February, 1915' .. 4 0 0 .. 0 -, 105 2 'September, 1914 .. ;1 0 ''0 - 0 -106 2 July, 1915 •• .. 2 0 0 - 0 '. -107, 2 ,September, 1914 ' ' .. 4 0 3 - 0 - ,

108 2 July, 1914· .. .. 4 0" 0 - 0' Macrostoma.. 109 2 September, 1914 .. 4 )0 0 - / 0' -110 2 Sept. and Oct., 1914 .. 2 0 0 - 0 - -;-

112 j ? 'July; 1915 ," .. 2

I 0 0 - 0' -

113 , 2 June, 1915 .. .. 4 0 4 - 0' -114 2 July and August, 1915 4 0' 0 .- 0' ~

.. =' .. - -"--. , --- -- -~"" ,

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446 . A. Bacteriolqgical Examina:tion of Convalescents

I;>YSENTERY CASEs-continued.

; AGGLUTINATION RESULTS ... ""0 \ '" .c '0 S "::'00

00 -E """ 00

i "'0 " ~ :§ .§ ., .~

15 '" ~~ Date of typhoid ~Bacteria and. protozoa B- "" "" '" 1;; ~'2'. ~§ inocuI~tions -: '" ~ ." 1.~

'.\ .. found . .~ -§'I'C "on f 'S.S 00 :<;<>1 ~:.2 0

~ >- >- "" ""ill " .c e " '" "'~ . .' , .. " 8< . 8<

'" Z .~ ~ ~.

" ~' CC; " c.::

/

I -'

115 2 May, 1915 4 0 0 > '3 . 0 Trichomonas;. . .. ..

116 -. 2 June, 1914 - .' . 3 0 0 - 0 -.. 117 L Decemlier, 1914 .. 0 0 0 - .' ~O B. dysenteria!(Shiga). 118 2 August; 1914 " .. .. 3 0 0 ~ 0 E. coli. 119 3 June, 1915 .. .. 4 0 2 - '0 -12i 1 July,1915 '.' .. '4 0 0 - . , 0 '-122 2 August, 1915 .. .. <1 '-0 2 .2 0 "

',-124 2 March, 1915 .. .. 4.

I

0 3. 0 0 -H6 2 March, 1915 .. .. 3 0' o .' '0 --127 2 " 1915 ' .. .. .. 4 0 0 - '0 128 2 July, 1915 .. .. 4 0 0 - 0 Macrostoma. 129. - 2 . December, 1915 .. 4 0 0 - ,0 E. histolytica, L. intes-

tinq,lis. 131 ? - 3 0 0 - ., 0 -133 - - 0 O· o· - 0 -134 2 July, 1915 ... .. ' 4 ,6. 0 ,- 0 -135 I L - 3 4 0 - '0 B. pamtyphosus A. 136 - - 3 0 0 - 0 -137 3 July, 1914 2 0 - 0 0 .. .. - -139 2 March, 1915 .. .. 0 0 4 - 0 --HO 2 June, 1915 - .. .. 4 0 0 - 0 -141 2 Septembe~, 1914 .. 4 0 0 - 0 , -142 ·2 - 0 0 0 - 0 -143 .. 2 April and May, 1914 .. 0 0 2 - 0 -144 2 August, 1915 .. .. 4 0 0 -, 0 -145 2. March,1915 .. .. 4 0 3 .3 0 B. 'dysenteria! Y. 147 2 I No,="". 1914 .. 4 0 0 0 Trichomonas. 150 2 August, 1914 .. • . 3 'I 0 0 - , . 0 -151 - 3 0 0 - 0 -242 3 Jan., Mar., Aug., 1915 .. 2 I 0 3 '0 .' 0 E; coli. I 243 2 March,1915 .. .. 0 0 .0 -- 0 E.coli. 244 2 January, 1915, .. .. 2 0 0 2 .. 0 -250 1 - 4 0 0 - 0 -251 2 - 4 0 4 - 0 -252 2 - 4 0 0 - 0 -253 .2 - 4 0 0 - 0, -5155 2 - 4 0 0 - 0 L. intestinalis, Macro .

stoma.' 256 2 - 4 3 o . 0 Trichomonas. > -257 2 - 4 0 0 - 0 E. histolytica. ..

DYSENTERY AND ENTERIC CASES.

154 2 - 3 0 0 0 0 -156 '2 - 2 0 4 0 0 -157 . 2 - - 3 0 0 0 0 '-158 2 January, 1915 . , .. 4 0 6 0 0 E. coli. 189 2 March, 1914 .. ." 4 0 4 '0 0 -, I

.. . .. .. . , .

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60 61

162 46 47 48

2 :2 2 2 2 2 2 4

49 M 59 81 96

164 166 167 171 173 174 179 181 187 188 191 .192 193 194 195 196 197 198 199 200 201 202 203 205 206 207 208 209 212 213 2i5 216 221 222

,-.

H. ~D~an, R .. Adamso~, J; Giles, and R .. 'Willicimson 447

. ': DYSENTERY AND ;ENTEiuc CAsEs":"'continued." ..

> AGGLUTINATION RESULTS

~! ,

I -a~ -~ ~ , ~o ~ ... ~

.!f . +=I ..... ~ ~ .§ Bact:eria and protozoa 'O~ Date.of typhoid -. "" ~ inoculations ~ ~ '" t; ~'2, found : ~::s ~~

I ~~ £:2 <0" ~

~""l .0 0

~ ~ S.S .z "" ~?3.<

" ] '" '" '" I ~ Z ~ ..

~ ~ . , "1

/

2 .: Ocj;ober, 1914 ... .. 4 '0 3 0 0 -2 October, 1914, .. .. 4 0 .3 4 0 -2 November, 1914 .. - 4 0 ,0 . 0 '0 Trichomonas. 2. February, 1915 '.' 3 : 0 3 0 0 -2 September,,1914 .. 4 O. 0 ,~ 0 -2 October, 1914 .. .. 4 0 '2 ,0 0 -2 - - 2 0 0 ','- 0 -2 April,1915 .. , .. 2 2 2 -2. " 0 2 '" .-' o. 0 2' , 0 0 -2 - 0 -0 2·. 0 3 B.dysenteria! (Shi~a).

- - 2 0 O~ '0 0 - :A - i t . .; -

ENTERIC: CASES;

2 / 0 0 I' 0 I 0 .. 0 - -' .....,

0 - 0 .0 0 '0 ·0, - .. -..

2 - 4:" 0 0'" ',0 .. 0 E.coli . 2 '. - 4 0 0 '0 0 E. coli. . .. 1 .. '

- 4 3 0 .'0 0 , - /

2 - 0 ..

0 0 '0 0 -2 .~ 0' 0 0 . "·0 0 - "-".

~-, - 0- 0 0 : '0 0 " -2 - 0 0 4 '0 0 -2 - 1 0 , : 2 '0 0 Macrostoma. 2 September, 1915 .. 4 0 0 0 0 -

- -I

4 0 4 0 0 -. ".2 Decelll ber, 1914 -. d . '0 0 0 0 -

2 September, 1914 '- 4 01 4 0 .. 0 -

2 December, 1914 .. 2 I 0 4 ". 0 0 -

2 October, 1914 .. , .. L I 0 4 0 0 -2 October; 1914 .. .. 4 0 3 '0 0 -2 September, 1915 :

., .. 4 0 0 '0 0 -2 July, 1915 .. .. 4· . '·0 3 0 0 ·E. coli. .2 '. - . 3 0 0 0 0 Macrostoma . 2 - i 3 0 '3 0 0 -. ,

2. I 0 0 3 0 0 L. intestin~lis. . 2 - 0 0 0 0 0 -2 1911 .. .. .. 4. 0 0 3 '0 B dysenteria! (Shiga). 2 , - : .'4

" o· 0 ,0 0 -

2 .. . - o· 4 0 2 0 -,

.~ " - 4 0 3 3 0 -'/ 2 - 0 0 0 ·0 O· -

2 - 3 0 .4 0 0 --2,

.. -- , 4 - 0 0 :0 .. 0 ., -2 - .4 .b 4 - 0 B. paratyphosus R 2 - !, 4 •. 0 0 0 i 2 - c 2 " "'- 0 0 0 0 0 -. 2 - 4 0 .. 0 '0 6 , --. ,

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448 ., .A-:BaQteriological EXa~li1Jation of Corivalesc,ents

223 224 225 226 227 228 229 230 231 232 233 234 235 238 239 241 260, 261 262 263 264 265 266 267' 268 269 270 271-272 274 276 278 279' 280 282 283 I

284 285 286 287 289 290 291 292 293 294 295 296 297 298

I

ENTERIC CASEs-continued.

2 2 2 2 2 2 2 2 2 2 2 1 2 2 2 2\

.2

2 2

'2 _ 2 2 2 2 2 2 .2

2 i2 2 2 2: 2 2 2 2 2 2 ?

, ? 2

2 2

'Date of typhoid . inoculations

August,1915 • • • • June, 1915' •. " September, 1914 •• October; 1914 •• •• July, 1915' ..... November,1914 •. February, 1915.. .'. Octob~r, 1915.. ..

.October, .1915 .• Nove:r:qber,1914' .. Jap,uary, 1915 .• .. Oct6ber,'1914 •. ' •. Dec., 1914,; Feb., i915

June, 1915 .• ;ran. and Feb., 1915 •• Febru/Lry, 1915 •• April, 1915 •• Japuary, 1915 •• September, 1914. August, 1914 .•

October,liJ14

June, 1915 •• •• June, 1915 •• •. December,' 1914 •• October, 19:1:4 '. • •• July, 1915 .• ..1 February, 1915 ... November, 1914· •• Novel1lber, 1914 .. Aug. and Sept.,. 1915 .. September, 1915 •. June, 191,5 .~. .. August, 1915 • • ,"

'.May, 1915 .. .. 1915 '.. .. •• October; 1915 ... ' •. May, 1915 •• •.

"'"'" ''October, 1915 .• • • 2 2.

August, 1914 •• . • September, 1914 "

4 4 4 3 o 4 3 4

.4 4 4 '

'4 , 4

4 4 3 3 o 3 4 4 3. 4 4 4 2 2 4 o 4 4 4 4 4 1 4 4' 4' . o 4 o 4 o 4 4 4 3 o o o

AOG'LUTINATION RESULTS

4 o o 0, o o o o o o o o 3 o o

'0 o o o o o .0 o· o . o ~O

o 0, , o ~O

4 O. o

,0 o o

. 4 o o 3 o o o o o o o 4 o o

,

3 o o o o 2 4-o

, 3 1 4 o 2

.2 . 3'

3 2 o 2 3 o o o 3 o 2 3 o 2 3

(4 4 2 1 1 o o 4 1 o 2 2

,0 2 o 3 4' 4 o 2'

I ~

,0 o o o o 2 o o o 2 o o o 2 o

'0 O. o O. o

'0 4 1 o o o o o o 2 o o o 2

,0 1 o 3 o o o

,0 o o o o o 3 o o

o '0 o o o

,0 o o o 3 o o o o 0' o o o o o o o o o o o o o o '0 o o o o o

1.0 o o o o o o

'0 o o o o o o o

Bacteria and protozoa . . found

B. paratyphOsus B.

E. coli.

. -

B. dysenteriaJ (Shiga).

E. histolytica.

E. coli. \ "

L. intestinaiis.

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H. 'pean, It.) Adams01~, J. Giles" a~d R.,Wil~iamson' 44~

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299: 300 301 302" 303 304, 305 306, 307 308 309 310, 312 313 314 316 317 318· 319 320 321 322 323 324 325 327 328 329 330 331 332' 333 334, 335 336

;337 338" 339 342 3M 345 346

2 " 2 ? 2 2 ? L 2' 2 ? 2 2 ? 2 ? ? 2 1 2 2 2 1

2 ? 2 ,2 ? 2, " 2 2' 2 2 2 2 2 2 2

,2 2 1 j

2 347,." -348" 349

350 2 '351 2 352, 2" 353: 2

AGGLUTINATION, RESYLTS

Date of typhoid .~ inoculatio~s

october, 1914 .;. October, 1914 September, 1915 March" 1915

:4 o

,3 4" o 4

Feb. and, March, '1915 'Jnne, i915 ', .• October, '1914 ", ,0

,,0 o o '0 o o o

April, 1914 ' •• ,Novemb~r; 1914 March, 1915 .• M~y, 1915 .. June, 1915 ••

11 I 2

3 4

. 3, o o o o

February,' 1915 / •• February,1915', April, 1915 \." J:anuary, 1916':.:. October, 1915, .1.,

July,1915' .• November; 1915 December; 1915 ,February, 1916 Decelllber, 1915 - •.

March, ;1915, " Aptil,1915 ..

.. ' Oct., 1914"Feb., 1915

3 ' 4;'

o 3 3 4 3 o o 3' 0, 4

September, 1915 ' .. ,.' 0 March, 191~.. •. 3 October, l\~:iji' .:. •. 2 October, 19l~ .. • • 3 September; +915 4 August; 191~,.:.· .. 3 May, 1915 '.:. .. 2 Feb; and March; 1915.. 4 SepteIpber, 1915 ' ..' 0 June, 1915, '.l. ..' 0 December, 1914, . . 4 March, 1915 .:. . .,2 l\1:arch.1915 •• .. \ 4 August;1915 .;. •• 3 February, 1915.. •• 3 March, 1915 .:. • . 4

I - '\

j January, 1916,. June," 1915 , -'. September, 1914 Qctober, 1915, :.

4 4 4'

3 4 o 4

4 o 4 o

, , 4

o 0' 2 0' o o o o o 0' o o o o 0' 0' 4 " or o o .0 o

! '0 0' o o o o o o o o

3 o 0, 3 o

'0 o 2 2

,I I, 1 4~

, 2" '4 3

'0 '0 ' 2 " 2 1 I' o 3 o 3' o 2 o

·0 4

-'4 3 0'

,0 0' 3 o 3 o 2 o o 2 3

4 2

" 2 2

,0 ,0

1 o o o o o o o o~ o o

• 0' :'0 o 1

,0 o o 1 o

- 0-1 o o o o o o o

,0 '0 o o o 2

" '0. o o o o o o 0'

3 o o o

Bacteria and protozoa found

o • "0 E. coli.

o L. intestinalis. o

"0 o o o B. paratyphosus A. 0': o

'0 O' E. 'histolytica.

'0 o 0, E. coli. o EJ. coli.

·er o o E. colf. o o

-,

-; , 0

0' ,t. intestinali§. o o o . o E. coli.

''a o o o o o .E. coli. 0' B. paratyp,!!osus A. o

'0 ' , "0 L. intestinalis.

'0 o Macrostoma. o o 0, o o o E. histolyti~a, Macro-,

stoma.', o E. histolytica.' i

0, 'L. intestindlis., o o

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450 A. Bacteriological' Examination of Oonvalescents, ~,' . .' ..

ENTER~C CASEs-continued.

- r , - AGGLUTINATION IRESULTS ,i' ,''''' ,

" '0 .0 . ,

":. S., -a~ ~. j I

~ ., >'0

'" .p.~

Date of typhoid ,

"" ~ !l !l~ Bacteria and protozoa t', ~~ '" '£ °t_· inoculations ~ '" found'

0 .. '" S § ~.~ .p ,,<> ~< ~~ I .~~ /

~. .cO . ~ ~~ ~~ . 0 S·S '" .0 " " ~ ,,~

" " "§ R, R,

>'l Z ~ ~ r:c; ~

,"" I

354 2 September, 1915 .. 4 ·0 3 0 0 --

355 2 June, 1915 4 0 2 : '0 0 -.. .. -356 2 August, 1915 .. .. 0 0 3 0 " ci -

357 2 Nov~, 1914; Feb., 1915 4 4 3 0 0 -358 'I June, 1915 .. .. 4, 0 0 0 0 -.'

359 0 - 0, O. 0 0 0 --360 - - 2 0, 3 , ''1 0 -,

361 2 November, 1914 0 0 - 0 . '/10 0 \ -

362 .' 4 4 0 3 ,I 0 - - -363 2 Sept.~ 1914; Aug,,1915' 4 4 2 ''0 0 -364 2 November, 1915. .. 4 - 0 3 '0 0 -

,365 2 July and'Sept., 1915 .. '4 0 '3 0 0 -366 2 " Aug. and Sept., 1915 : .' .4 0 ,3 0 0 ,-

367 2 May, 1915 .. .. 4 0 '0 '0 , O· ,-

368 2 November, 1915 .. 4, 0 2 1 0 -3,69 2 March, ,1915 .. .. 4 0 3 ''0 ',4 -370 2 February, 1915 .. o. 3 0 3 '0 0 -

371 2 October, 1914 ~. .. 3 0 0 '0 0 -37'] 2· , November, 1914, .. 4 ,0 4 '0 I 0 L. intestinalis. 378 2 May, 1915 .. .. 4 0 2 2 0, - . 379 2, July, 1915 ., .. 4 /0 3 2 0 -380" 2 October, 1915 . , .. 3 c 0 ·0 ' 0 '0' L.intesti~alis. 381 2' March, 19.15 , 4 4 3 2

.. -0 -.. , ..

382 2 March, 1915 .. .. 4 0 4 ,1 0 -383 2 .. ,_!January, 1915 ... .. 2 0, ' ,3 '0 0 -

385 - 4' 0 2 3

I 0 -,

386 - 3 0 0 0 0 ~

387 2 1 September, 1911\ .. 4 0 4 O·

I 2

390 - I ' - 4 0 2 0 0 -

391 2 I May, 1915 , .. .. 4 0 3 0 0 • -392 2 I May, and June, 1915 .. 3' o· 2 0 0 -393 ~ - 3 '0 2 '0 0 -394 .2 April, 1915 .. . .... 4 " 0 3 0 0 -

395 2 Augnst, 1915 .. 4 0 3 0 0 ,. -396 2 Sept., 1914 ; July, 1915 4 ,.0 2 '0 0 -

397 - '4 0 4 0 0 - "

398 2 I Nov.ember,19H , O· 0 2 0 '0 -400 2 April; 1915 •• .. 2 0 2 2 0 -

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H: Deali R. Adamson," J, Giles, and R: 'Williainson451

PROTOZOA: 1- "

By·R. WILLIAMSON'. -" ' , '." ,.I" " , '

Microscopic exall{inations were made of 180 convalescents who had been diagnosed as dysentery., The majority were examined on

,three occasion,s and,.in several cases additional examinations were' made. ',)The,resuiti of these examinations is given in Table n.

'.l

, '

TABLE IL'::'DYSENTERY AND DYS~j'lTERY AND E~TERIC: Number of cases .. ",

examinations d

, c;tses'in which parasites were found' " 'E. histolytica was found' ",' 'E. coli waifound, '

'-Lamblia was fou~d ' c"

,',. , Macrostoma was found ~ ,:

.: ~

"

,,' Mixed infections .,

Trichomonas was found 'Cercomonas was found '

Coccidian cysts were' fonnd, T-fichocephalns eggs were found

_ E, coli and Macrostoma. • ",,' E. 'histolyticd'

,E, histOlyti~a and :Macrostoma '" ,; Lamblia

L.. 'intestinalis ami' Macrostoma

.'.

."

180 589 53 8

15 "-21 8 4 1 2 2' 8 2 1 1 2 2

As from,se:yeral of our cases, in which' a diagnosis of enteric ,fever had been made, bacilli of, the Shiga type were isolated, it was thought desirable to 'mak~ a mic~oscopical exaPlinapion 6f the /freces "

,of such oUhe enteric cases as had :not been discharged. Th,eresults of this examination are sha'wn in T~ble Ill:

~1

TABLE IlL-ENTERIC CASES.

Number of cases

" "

",

" ;-"

examinations .. 'cases in' which parasites were found

" " ,E. histolytica was found " '" ' E. coli was found, '

,Lamblia was found

," "

; , Macrostoma was found Trichomonas was found , ,),

" ,C£rcomonas 'was found· ". Coccidian 'cysts' were found:

" " " Trichocephalus eggs were found :rilixed infections

E. coli and Macrostoma .. " ;,' : E. histolytica

E. histolytica and Macrostoina '

'\

259 327 42

, 7 18 14 6' 1

,0 0 0 3 1 1 1

, I

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452' A BacteTiologicalExc,;!ninationojOonvalescdds ,:

. .' . _ ,METHODS. . . \ . . . . .

, Specimens oLfmces. were collected and placed in an incubator. I As a rule about three,homs,elapsed, before. the examin~tion ':vas ..

made. Neutral' red in the proportion of 1 to 10,000' parts of .normal saline :solution was' used to dilute the -{mces. Both the saline ~olution apd the glass slides w.ere brought to a temper~tme' of 40° C. before use. In some case~ :permanent prepar.ation~were made. ';"Wet films were fixed in hot Schaudinn's fluid for -five mInutes. 'They were· then' stained by Heidenhain's .iron alum' hmmatoxylin' orhy h,remalum .. / .'

\

ENTAM<EBA 'HiSTOLYTICA.

This parasite was found iil 8 of the 180 cases (4~4 'per '~~nt) . diagnosed _as ~ysentery; and in 7 of ·259 cases (2'7 per cent) diagnosed as epte.iic fever .. , The majqrityof the enteriSl cases, were only e?,amined once, while . the 'majority of the dysentery (laRes h'ad

, three. or more ex:arriinations; In one case only was E. his'tolytica ' foundtogeth Efi'~i th a pathogenic . bacillus, . (13 .paratyp hosus 'B). .

. Except in Case 86, ,the. appearances obs~rved corresponded to the us~al.descriptions of ,the parasite. Both cysts .and "active · .forms were. frequently observed. ' ' , " . I

\

NOTES ON' AM<EBi. CARRIERS .

. No. 43. " Dysentery at Suvta Bay,~eptember 29, 1915: .' Stated :- to, have had t~oinjections " of emetine. Had 'had diarrhooawith

hmmorrhage in fmc{ls ih Egypt; Tetragena cysts a!J,d v.egetative phases observed J,anuary 12, February 9, and 15, arid March '3.

· Six. one-grain doses of' emetine Marqh'Tto March 14> Very few' · amoobm !oundMarch 13., Examinations ,April 25, June Sand 15 were negative. Patient's serum agglut'inated B.typhosus only: Condition' 'at time of admiss~on good', stools normal" but three

, , I

motions.R day. . , - ,,", "-No. 83. Dysentery atSuvla Bay, September 2.7, 1915,. Stated

to hl),ve had twelve injections of emetine::-- Examinatioil January 13 'negativE<, January 27 and February 7. few amoobm found. Examination March 3 negative. Six grains of emetine injected Marph 7 to March 14. ' Examinations March 13, April 25; June Sand 15"

,; negative.. The' patient's' serum agglutinated B .. typhosu; and B. ' pa/ra.typhosus B. Condition on admission good,' motions. one' or. two, dlii)y ~nd appearance normal. " . ' ", .

No. 86. Dysentery at Alex~ndria~ O~tober 11,,1915, where: three

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H. Dea~,' R. Ada'mspn, J.'Giles, and,R.Willianison 453

" iiljections~f ~metinewe~e giveIl. 'Amoobre observed on January 27 t , \ February 7 and 25, and,M,arch 13. The amoob~!were s~al1er than' , ,

, typical E. his to ly tica and usually ,spherical~ A,few active forms, were s.een.' The 'nucleus was invisible, but ectoplasm, and endo- \ , plasm wer_e not sharply di:ffe'rentiat~d. 'N,ocys'ts were found.' This' ' paral?ite corresponded in som'e respects\yith. the deseriptiollo( E. minuta. Six gr~insof emetine given Match7t0 ,13:.' Amoobffi., obseJ;ved on April, 25. ' Six doses ,of enietine given May 1 to May 8. Examinations o~ June 6" 15 ~nd 21 were negative. ' The serupl / agglutinated B., typhos,,!s only; Condition on admission wasgood. '

-St~ols norina!. !, ': '.' ,';' , ' : ," ' " "" ,I /' ,No.68. Dysentery, Cape RelIes, September 9, 1915;-:-Amoobre ,~

. ,

found on \Januaryl3 and 31, F~bruary8, March 3"Six injections of emetine March 2 to 9. Amoob~ observed 'March 13, Apii125, Jun~6and 15. ~secondcourse oi'emetine injections was given in May.' In addition ,'to E. histohJtica the freces contained large

, num,bers of, Mactostoma.' The amoobooobserved after the emetine' ' , were few in number and appeared to be degenerate~ Emetine had' no influence on Macrostoma . . The tilerum agglutinated B. typho,sus, The patient ~as' in go()d 90nditiori con _adlllission. ' Thenumher 'of motions w~s four to five 'daily. ' , /"- " "

'NOr 70. Dysentery, Suvla Bay,bctober2~ 1915.-Lamblia cysts: , found "onJ anuary 13 and 27., On February 7: Lamblia cysts ,and , ' E ~,histolytica wer~ found,' and on,' MarcQ '3 Lamblia cysts only were, ,

found. ~ . After ,this date Lamblia 'disappeared., "Exaniinat~ons made ,on March 13 'arid, April ,25 proved negative. On June 15, E.,

',Jiistolytica'w!ts again f~Ulia:, but was absent onJ une ,21 and July 5. Twelve, grairis.of, emetine were given commencing 'on July', 7, but

',. the- patient was transfertedbefore further eX!1minaJi9ns could be 'made.

1

The serum agglutinated B. 'typhos'us only. On admissioll the patient:s condition. wa& good hut he had not quite regained

-weight.; Re was .said to have had enteric one"month after dysentery. No. 138: 'Dysentery at Suvla Bay at the begiiming ofNovemh'er,

,1915. Stated 'to :hav,e had emetine at Malta.' Cysts andvegetativ!? phases ofE. coli: were found 01} January 19 and Febhiary, 16 and 21, ,on March 3~and April 25 in.addition to E.coli'a few.active spec,im!ensof E.\histolyticaw,ere fqund; On June 6~ 15 and. 21 . only E: .c6,li :was found. Whether he. had· pad emetine between Aprit25 and June 6 is uncertain. 'Agglutination reactiqn was not·, tested. 'Pa,tient'scondition onadmiss1on was good.. . ,

'No. 257. < Dysentery,Suvla Bay, September 15, 1915. Jlad had injections' of emetine. A few cysts and, vege~ative fo,rms of

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454 . A Bacteriological 'Exami~ation of Convalescents

E., histoZytica were found' on February 2, 8 and 21. The patient' was dischargedb~fore further e~amination~~ould-be made., Ser.uni

i.agglutinated B, typhosus only. Patient'sjcoriditiDn on admission' ',was goDd. - . .

·'No.129. Dysentery, Capt. He lIes/early in September, 1915. Had hadihiectio!;ls 'oJ emetine on the Peninsula. A'few speciIY!enso£

• E. histolytica 'were found on February 10,16 and 23 and on June 6. -, : On-June 15 ·and 21 noamoobrn were seen, but a few Lamblia cysts

were presebt on June 15. On >July 5 E. histolytica anda few Lamblia cysts were seen. Twelve one-grain doses of etiJ.etine we~e_ started on July 7 but the patient was trapsferred- before other .examinations could be. made. The serum was not examined. ,Th~ patient was in good', ~ondition /on admission.

. No. 350. Enteric, Peninsula, erid of November,1915. AJew !specirriens of E. histolytica w'ere fouIld on March 29 and 1Yhy 10, On May 17 the examination was negative· bQ.t on June 7E. his- ' 'to/ytica was· again; found. An examination m,ade on June 15. was negative but' on Jlihe 21 a few active .E. histQlyt-ica, were found. A 'negative' result was obtained on July '5 .. On July 7 the patient ' was started on a course'of twelve one-grain doses ofenietine., The patient. was transferred before further 'examinations could ,be made. Patient'S' serum, agglutinated B. typhosus, ]J. pamtyphosus Band·

.bacillus'Y. The patient had four days diarrhooa with abdoITlinar" . pains commencing May 19. . " '

,No. 349. This man was admitted to, Hope Hospital as, an' ' .enterieeonvalescent. AccordIng to patient's .story' nehi1d had. . dysentery at Srivla Bay, November 18, 1915 and was sent.to St . .J ohn' sHospjta], Malta, where he d&velq,ped. enteric fever. ,On. March 29 and May 3 E.' histolytica and Macrostomaobserved.

<Six grains of emetine were injected between May 3 and May]O. 'l'he exalnination was negative on May 10 as regards both'pftrasites but positive on May 17. On June 6 and 15 E: histolyticawas

. not found. Mac1'ostoma was present on the (3th .. Both parasites were found on June 21 and July 5. On July 7 a course of.tWelve

. injections of emetine was commenced. The patient ,was shortly afte:r;wards removed from Hope .. Tbeserum agglutinated E. typhosus and B. paratllpkosusB. The patient's. condition' was

\, good except for it chronic sinus of lower jaw, which appeared to :improve m~rkedly after emetine i'njections.

No. 283. Developed jaundice in October,1915, at Suvla Bay, treated at field ambula~c~ and returned to duty, s)JbsequentIy sent to hospital at Malta for" trench foot':'.developed enteric in hospital.

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H. Dean, R. 4darnsollr J. G'iles, and R. Williamson 455 . - . . . -, .

if:. 1~ist~lyticC!' waf3 found on ,March 30 and May 10 but not, on··J ~n~ '. 6. a~dMay' 21;' ,Seruni agglutinated 1/. typhOStlS. Onadmission the patient was very weak and thin. ',He suffered from csmstipation , '.'. ' '" . , ' ,_ I during stay III Hope Hospital. " " '"

" " No. 392." Entedc at Salonic~, ,Nov,el)1ber f915, in' hospital at , Cairo ,n weeks. ' E. j~istol!Jticafound' Apri126;N ega:tive results ..

obtained on May 10 and Jun'e 6. Positive results on June 15 and , Ju~e 21. ' .. The serum agglutinated'B. typh~sus. The patiJnt's con-, , dition ""as good at time of examiriations. ,,'~". .

, '. No. 446.' Developed diarrhooa on ship leaving Gallipoli Peninsula, Admitted to, 15th/General Hospi.ta,lat·Alexandria on 'December 25

. (diagnosis, 'diarrhooa' and pyrex'ia). In this, hospital three weeks, then at convale.scent camp, and the~ two weeks at base camp.:

, Admitte'd 17th Qeneral ;S:ospitalat. Alexandria as case of e~teric·. fever. E. histoZytica ~was found on May 9 and 17, 'but not on June ,6,15 and 21. Cysts ofE. coli observedcat exainination on M~y 9. The patientsufferep from constipation during stay in hospital. . " No. 310,.. 'Inhlidedfrom Gallipoli Peninsula with diarrhooa. "

-: Enteric fever at Alexaildr~a, J amlary ,11,1916.. E. histolytica were present in large numbers in fffices on 'March 28' and 30, April 6· and 25,May io !1nd 17 .. Six doses of ,emetine were giv(3n in'June. On July 5 fewer a,mcebfl:! wel'eJound .. Subsequently twelve more. injections of emetine were given. . Tpe' patient ~as remov,ed, from Hope in July. The serum agglutinated B typhosus: The patient's. condition was good. ; " "" . . ' .

No. 429. In 17th General Hospital at Cape Helleswith--diagnosis, of enteric/fever. 'Subseguently sent to Cairo. E. histolytica found on April 27 and 'May 10. 'B. pai'atyphosus B isolated from .fffices ' on 'April 17. 'Serum "'-agglutil)ated B. typhosus and, B: para-' 'typhosusB ..

EM:ETINET!'tEATMENT 'OF. CARRIERS,

. Several of' the cases were removed: to dysentery camps before' the res~lts of ,erne,tine treat~en't could be appreciated.

In the ca~e of six patients t~e results above given provide data" of someinteresC' in three cases the parasite disappeared from the

, fffiees;' and thre~ negative results Wereobtained"the last of 'which . was at least three months .later than the date of the~emetine injec-tion.s~ . In one Case ,(68) the injections' appeared' to have·'little, if any, influence on the condition,.. In two Cases (7.9 and 349) the' examinations 'immediately 'following the course of injections were negative, but the P!1rasite -subseque~tly reappeared. . ,

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:456 A , BacteTiol~gical' Exdinination of Convalescents

ENTAM<EBA COLI.

This ,parasite was obse~vedin 15 of the 180 dysentery ca~es, :and:in,l'S of the, 259 enteric ca!le~. In the 1;liajority of cases very

, ',few amoobre .were ~ seen.' In nearly every case a few: cysts' were , -seen as well. as the vegetative forms. I!ltwo patients both, E. coli ".and E. histqlytica were found. ' / -

LAMBLIA INTESTINALIS. ' ,i

'This parasite was obs~rved in 35 ,of ,439 cases; lS0·had been .diagnose'd as dysentery, and almost'all were exarnined- on at least' three occasions, and the parasite was found in 2l cases. ,', Fifty-nine had been diagnosed' as enteric fever" the majority" had only one

'microscopical exaplination, and·theparasite was found in'fourteen .cases. Of the dysentery-cases the,Lamblia was found in 3 o'f-3 ' examinations in 7 cases, in 2 'of ,-3 exarri~nations in 9 cases,.in 10£ .3 examinations in 5 cases. Of the ,enteric cases eleven were only

, 'examined .once, three were' examined twice, 'and the PfLrasite. was found on each occasion. Encysted forms usnally occurred, but .in

, five', cases active forms were seen. In thirteen cases the' 'cysts were numerous. Almost ,all the patients were in g?od ,health 'at the time of. examination, but 'several suffered from diarrhooa \ dliring their :stay in ,Hope Iiospit~L In' this respect there was no - striki'ng .difference between these patien'ts and the other,convale'scEfnts;

, From one of the thirty-five B. dysenterice (Flexner) was .isolated. , In two cases E., histolytica was' observed.. The serum 'Of one

patient strongly agglutinated B. paratyphos1.ls A; of 4,B. para-\,' ' ,-' , , ,

\ typltoSll.s' l3; :that is to say, in 9 of ·the 31l. cases there was good evidence of. some' other cause of disease.' '

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MACiROSTOMA. , '

This parasite was observed in 8 o~the 180 dysentery and 6 of the 259· enteric cases. As a rule, very few ltfacrostoma were seen ill each specimen,. but occasionally they were VEiry numerous. Active forms were far more numerous than cysts., In those cas'es in which the 'parasite,occurred in large nu'mbers it was found,at almostr every exa~ination. '

MIXED INFECTIONS .. . '.' /- - '.. -'./

(1) PatIents who were found to be,'cai'l'lers of mbrethan one , pathbgenic 'organism. ,Only two cases' come, under this heading. Iilone Case (429) B. paratyphos1.ls Band E. histolytica were found.

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}I. D~an, R.4-damson~_ J: <!iles;'and R. Willidmson457 , ' . \-. . .

-A brlef history of ~his ease will be found amorig the notes, on , ammba car-riers: In/the otber Case (424)' both-the FIElXIier and Y type!? of B., dysenteria3 ,appear to, have beEmpresent in the sailie patient, An,account,ot this c;ase is 'give~ undeJdhatheading., The' seruni of this-, man agglutinated the Y,bacilh;ts 'and B: pam-,typhosus B. ", '

(~)' Carriers wh0se 'serum agglutinated .erpulsions 'of' other pathogenic ?~ganisrris:

Case

I Clinical 'I,

.. diagnm.,is

-}"

Organism" found in.freces .

.\\

AGGLUTINATION REsIH:rs WITH PAl'i~N'I'S SEIlU~f. . / " . ,-'

Typhoid Para ..

typnoid -!>- '

----,-.' ----'---' --'--'---'------' --' -' -" --'-' -'--'-'--E. '1iistotyjica 83 D

349 E 350 E' 145 DYbacill;;s,

'263 ,I -~\~ "Shiga bacillus

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,4 4 3

-4, 4,

o o o o o

4 3 <1 3, 3

o 3 3 o

, I o o o o o

Notes on ,83,:34;.9 and 350 will be found under heading of amOflba carriers. In the case of 349 there is a"definite'history of dysentery contracted at- $uvla- Bay, and enteric in J:1ospital at Mal~a. The histories of the other easel} afford no,- evidence of double infection,. n\vill be observed that two of the E. histolytica cases' and the Shiga case were" diagnosed as enteric fever.' . - I

(3)'Patients ;Whose serum definitely agglutinat-ed ~ore thanon~ pathogenic 'baciHus.

I I - AGGLUTIN.A~IdN "RES~LTS WITH .'PATIENT'~"SERu~r' ,

Ca~e ' Clinical jdiagnosis

, ,TYPhOid -- I p~rati~hoi~ I paratbPhoid , ~ / Y bacillus Shiga

-------------- - _____ -1 __ - ----- ----161 D and E 4 l 0 3 4

, 0

- 208 E 4 0 3 '3 0 223 E 4 . I' 4 , 3 ,0 0 276 'ID 4

f I 4- 4 0 0

285 E , 4 0 4 3 , 0 296 E 0 4 I 4 3 0 312 E , 3

\ 4 4 (0 0

314 iE 3_ I 4, 4 0 0 357' , ·E 4 4 3

, 0 0,: 369 -- ' ,,,'E .4 0 I 3 0 4 381 E .. 4 :4 .. 3, t ,2 0 387 E 4 0

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458 'A Ba:cteriolo.gical Exa1nina:tion of Oonv~lescents

;" ' '< Sera from' two c~ses diagnbsed' as enteric ~ever agglutinated the Shiga bacillus and the Paratyphoid B bacillus~ _ Patient 069 con-'

'-- traded enteric fever on the Peninsula In Noveniber; was sent to . -\" -~ , . '.. - , , ,~ -'

Cairo" where he- had a I, relapse." -Patient 38~contracted el)teri'c 'fever ~t Salonica 'on October, 27. " Sera from five ,cases agglutinated' ,paratyphoid B an9, bacillus Y. ,Oue case (161) was' diagnosed, , clinica,llyas enteric fever and dysentery.' ,The other three patients' " we're :diagnosed ,as en tericfever, and such particulars' of them as are in our poss!3ssion aff01:d no evidence of ,double infection. Sera:frcim' sey{in cases agglutinated,emulsjons of both pa'ratyphoid A ,and B. One of these was: the patient M., and some account of this case, and of -, the' bacillus' which was isolated, is given under the heading of hacilli ~,'_ belonging to the paratyphoid group. We consider this bacillus to ' be closely allied' to, brit ,a~epai:ate variety from B paratyphosus A.

Higher dilutionsfi-om 1 in, 100 to 1 in 1,600 were prepared £.r0111 five of these sera. In one case (312) par~'typhoid Awa's agglu;-

, tinated in a dilution of 1 in 100, paratyphoid B in a diltitionof 1 in -1,600. In the,othercas!3s the differences in the titre of the serum with enlulsions 6fparatyphoid A and B were incons(deraole;and we were unable to arrive at any definit'e conclusion. 'J

SUMMARY.

Four hundred aiid eighty:eigbt cas'8s from the Mediterranean, Force were examined. OLthese 308 had been diagnosed as enteric

-.- ,fever, 160 as dysentery, and 20 as dysentery and enteric. ' In no case was' B. typhosus isolated from either fmces or urine.

B. pamtyphosus A was i,solated from 3 cases, in 2 c,ases from freces; in l cas~ from urine. rrwoc,ases had' been diagnoseqas enteric, fever and one as dysent'ery. Serum (rom these patients

'agglutinated an emulsion of paratyphcislis A. B. pctratyphostls B was isolated from three c8zses, all of which had '

been diagnosed asent~ric fever, an'd in all thr~e cases the bacillus was found in th'e freces. Serum fr01n' tnese patients agglutinated an' emulsion' o£ B. paratyphosus B. - B. dysente1'ire (Flexner and Y types)'.-Strains fermenting mal

tose were isolated' from two patients,. The serum from one of these , , agglutinated an emuJsion of the stock'Y bacillus~

Stniins which did not ferment maltose 'were isolated from two 'cases. T,he serum: from one of th'ese patientsagglutipated the stock ' Y bacillus.,' ,

Froni one patient were isolated. two strains, oneo£ which fer-'

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. ,:E!. De,an,!t. Adam"Son, ~ Giles,and R. WillialnSon459

mented maltose, while the other did: not. The [lei'um of the patient agglutinated the Y strain, but not th~ Flexner-strain.

B: dysente/~ice (Shiga' type) was i~ola.ted 'from six of the 488 cases.' Of these,2 had been diagp.ose'das dysentery,3'as enteric fever, and· 1 as dysei1teryand enteric. The serum from three of these patients.' agglutinated an emulsion of the stock Shiga,bacillus.- '-

'. E. h istolytica was found in fifteen ofA39 cases. ,Of these seven had' been diagnosEld: as enterlc)everand eight as either .dysentery or: dysentery and enteric. ,,' ' , , Of 488 convalescents 3 yVere' found to harbour B. paratypho8us

i

A, ,3 B. p'al:atyphosus B, 5 B .. dysenteriiE(Flexner) 6 B. dyselitel;ice ' ..... (Shiga), and 15~E.histoly't1:ca': . Only 259 6fthe 308 enteric cases were' examined for amoobm; ,'The ,total. nu;nber of carrlersamong the 488 was 32, that is to say, rather moretban6'5 per cent. . ., Other Bacilli . .-:.....Six. s.trairt.s were. Isolated which. were' probably.

men1Qers of the paratyphoid family. 'Investigatiol;ls ofthese strains are being continu,ed.· In many Qther cases the MacConkey plates Wtlre covered w:ith, pale colonies,. which proved to-be varieties, of bacilli not as yet ,associated' with pathological changes: A short account" of the strains ",hich were isolated and examined has been given. above. , ~ ,

'1'he results attained by an examination of the Sera of unselected cases may be summarized as' follows. No 'slight or doubtful reactions have been included:- -

Number of cases Enteric Dysentery.. . ,', Enteric a-nd dysentery' All cases ,;

:Xumber of cases'

171 130

16 ,317

, Enteric, . . 171 Dysentery •. ' ,i31 Enteric and dysentery 16 All ~ases • .' " 318

Nlilil ber of cases .

Enteric ',.. , 170 Dysentery. . ' . ,~, . 7, Enteric andClysentery 13 All cases ,.. .. 190

Paratyphoid A.

Positi ve reaction ~ 17

., 1 0

18

Paratyphoid ~.

'--Positive reactions

Y bacillus.

.. "

Positive reactiops 8

'2 ,I '11

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~ercentage

10· .' 0'7 -5'6

Percentage . 35

14'5

.; .26'4

Percentage

~'7-

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460 ,A' Bact~riological Examinp,tion 'of Oonva~scents,

" Shiga bacillus. , 1\ mu-her of cases Positive re~tions , Percentage'

, '2'3 Enteri<l' 171 4 'Dysentery. . . '132 Enteric'imd,dYEentery 16

'.. .6 : . 8 ./'

1 ;. .. , .'-,

, All cases .. ' . . 319 ., 13

- , ~ '. 'The number.of sera which strongly agglutinated the two varieti'es

, ',of paratypho}dbacilli A and B was large, and if only those c'aEles are / included ill whic4a ven; strong reac'tion was obtained, we arrive '

at the" corH::}u.sioh that thirty~three p'er cent ofa-ll patients, had' sufferedirom paratyphoid infections. The percentage -for patients clinically diagnosed as' enteric,is forty-five.' ' '

. The figures obtained witj:l.the two types ofdyhentery,baCilli-are , much lower. " Here ,the results obta.ip~d bY,the agglutina,tion method pr9bably do not' provide a reliable index of the prevalence of bacterial dysen'tery. The ,serum of only half ofthe:aysentery carriers· agglutinated the homologous strain of dysentery bacillus"Moreover, th~ titres of th~, sera which did agglutinate either bacillus Y or the Shiga.

" bacillus were much lower than the titres of most oC the sera which ,agglutinated the two varieties of paratYr>hoid~ ,

,The cases of amcebic dysentery treated by emetine were hardly TIunier'ous enough, to afford valuable " .information. 'l'he results obtained appeared to show that e~etine 'injections produced, the dis~ appearance or reduction in numbers of the parasi,te~ In a few cases ):lOwever, the parasites, after an interval, reappeared. ' ) , . .The fact that B. typhosus was In no case isolated from either fIDces or urine is evidence of the 'v'alue of preventive inoculation.

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