NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
17
The following table shows the result of the examination of the blood, urine,
and fæces of the healthy individuals :—
N A M E .
WIDAL REACTION.
B. TYPHOSUS.
R E M A R K S .
B. typhosus. B. paratyphosus
B.
Fæces.
Urine.
1. L. Corp. T.
(father of pati-
ent).
Negative, 3rd
July 1906.
Negative, 3rd
July 1906.
—
—
The T. family arrived
Kasauli 26th April
1906. Mrs. T. had
an attack of diar-
rhœa for several
days from 7th May
1906. She was in
close contact with
the boy T., who
developed enteric
about the end of
June 1905. She
was a " bacillus
carrier."
3rd July 1906. 3rd July 1906.
2. Mrs. T.
(mother).
Positive, 1—80.
Complete, 3rd
July 1906.
Negative, 3rd
July 1906.
Present, 8th
July 1906.
Present, 9th
August 1906.
Absent, 10th
August 1906.
—
3. Thos. T.
(brother).
Negative, 3rd
July 1906.
Negative, 3rd
July 1906.
—
—
Mrs. C. was a next-
door neighbour
of Mrs. T. and had
associated with her.
3rd July 1906. 3rd July 1906.
Mrs. C. developed
enteric about the
beginning of July.
4. Jos. T. (brother) Negative, 3rd
July 1906.
Negative, 3rd
July 1906.
—
3rd July 1906. 3rd July 1906.
Neative, 30th
August 1906.
There can be little doubt that the mother, Mrs. T., a " chronic bacilli carrier,"
infected her son, with whom she was in very close contact. Further, her relations
with her next-door neighbour, Mrs. C., the second case of enteric fever, were
intimate. This observation again shows the important part which the " chronic
carrier " plays in the propagation of enteric fever.
(3).A " c h r o n i c b a c i l l u s c a r r i e r " i n t h e S c o t t i s h R i f l e s ( C a m e r o n i a n s )
and in this unit a considerable number of enteric fever cases occurred.
In examining a large number of healthy soldiers at Meerut, from the differ
- e n t u n i t s s t a t i o n e d t h e r e , o n e m a n w a s f o u n d t o b e e x c r e t i n g B a c i l l u s t y p h o s u s
in considerable numbers in his fæces. He belonged to the Scottish Rifles
(Cameronians) and had been a nursing orderly on enteric cases. He had never
suffered from enteric fever. It was a noteworthy fact that seven out of the ten
cases of acute enteric fever which we examined at Meerut came from this unit
MOB
D
18
The connection between this " carrier " and the cases of enteric could not be so
clearly established as in the two above described epidemics, but the fact is
nevertheless very significant.
The following table shows the result of the examination of the blood, urine,
and fæces of Private 6934 R. J., B. Coy., Scottish Rifles, Meerut :—
Number, rank, name,
and
Regiment.
Date
of
examination.
WIDAL REACTION B.
TYPHOSUS.
B. TYPHOSUS.
20
40
8 0
1 2 0
Urine.
Fæces.
No. 6934 R. J., Cameronians,
B. Coy.
14th February
1907.
+
+
+ —
—
++
The following table shows the result of the examination of the blood of the
other cases admitted from the Scottish Rifles, Meerut:—
Serial
No.
Number, rank, name, and
Regiment.
Date of admission to
hospital.
Date of examination.
Bacillus
typhosus
in blood.
Widal
reaction.
1 Pte. M., Cameronians, A.
Coy.
19th February 1907 1st March 1907
+
Complete
1—80.
2 8422 L.-C. K. W., Cameroni-
ans, G. Coy.
5th March 1907
7th March 1907
+
3 850 Pte. B. W., Cameronians,
G. Coy.
1st March 1907
1st March 1907
—
Complete
1—320.
4 8367 Pte. E. B., Cameronians,
D. Coy.
31st December 1906 31st December 1906
+
5 8544 L.-C. T., Cameronians,
D. Coy.
24th February 1907 28th February 1907
+
6 8534 Pte. A., Cameronians,
D. Coy.
25th December 1906. 25th December 1906
—
Complete
1—320.
7 8691 Pte. M., Cameronians. 12th December 1906 18th December 1906
+
8
8969 Pte. K., Cameronians 12th December 1906 22nd December 1906
+
(4) An epidemic of enteric fever in a Convent School at Poona. —This
epidemic is of interest because the source was found on investigation to be the
cook of the school, who had passed through an unsuspected attack of enteric
fever. He infected a certain number of children before he went on leave in
June 1907, and again on his return he infected another batch of children in
July 1907.
This is an instance of an individual excreting the bacilli and dealing at the
same time with the food supply of a large number of individuals, the result
being, as previously pointed out, an epidemic of enteric fever. This man was
at work during a considerable part of his illness. He was, probably, excreting
1 9
bacilli in his urine in large numbers. He was, in fact, the reservoir from which,
the supply of bacilli which infected the children came.
None of the children could be shown to have contracted the infection
whilst he was at Goa, but following his return a fresh epidemic took place.
The after-history of the Goanese cook, B. S., was very interesting. He was.
admitted to the Sassoon General Hospital, Poona, in October 1907. He had
signs and symptoms pointing to an affection of the gall bladder, Examination
of his blood on October 9th showed that the Widal reaction to B. typhosus was
nearly complete in 1—10,000 dilution. On September 5th his Widal reaction to-
B, typhosus was 1—100. Therefore between September 5th and October 9th
his agglutinins had increased very greatly, pointing to the fact that the B.
typhosus was still present in his body, probably in the bile, and agglutinins were
being manufactured. His symptoms indicated that there was some affection of
the gall bladder, probably produced by the B. typhosus in the bile, and this con-
dition probably interfered with the discharge of the bacilli from the gall bladder,
and hence the difficulty of detecting them in the fæces.
The man left for Goa in October at his own request, so that further observa-
tions were not possible.
The following report is by Captain D. Harvey, R.A.M.C.:—
REPORT ON OUTBREAK OF ENTERIC FEVER IN THE CONVENT SCHOOL,
POONA.
July and August 1907.
The school is situated in the centre of Poona Bazaar, and the buildings
of the institution are completely surrounded by a wall of six feet in height. The
dormitories and other buildings of the school are arranged in the form of a square,
which encloses an open space. Three sides of this square are built in proximity
to the surrounding wall, but the fourth side is separated from it by a space of 30:
yards. In this space the cookhouse, which is built against the wall, is situated.
A narrow street runs all round the outside of the Institution between it and the
houses in the bazaar. There is accommodation for 150 boarders, and the children
include Europeans, Eurasians and Native Christians. The management is in the
hands of a Roman Catholic sisterhood, who pay the utmost attention to the clean-
liness of the premises and to the care and comfort of the children. The food
supply is ample ; water is taken from the municipal mains, and all the milk used is.
boiled under European supervision.
Although plague has raged in close proximity to the school, there has.
never been a case of plague in the Convent, nor for 15 years has there been a
case of enteric fever although this disease, also, was prevalent in the city and.
Cantonment.
D
20
About the 17th of July 1907 three of the children, Daisy R., Annie F.,
and Josephine C., were noticed to be ailing ; they refused food and complained of
headache.
They were admitted to hospital on 21st, 22nd, 22nd July, respectively,
with fever. As there had never been a case of enteric in the Convent within the
memory of the present nuns, this disease was not at first suspected ; two other
children who had also been ailing for some days were admitted on 25th and 28th
July, respectively.
The Staff Surgeon who had been called in to see these five cases, suspected
enteric and the serum was sent to the Divisional Laboratory, a positive reaction
to enteric being obtained in all these cases. Naturally this result put the nuns on
the alert, with the result that the second batch of cases was diagnosed at once.
Hence the date of admission to hospital in their case coincided with the date of the
onset of fever. This is well shown by the charts, the temperature falling to
normal on the 21st day in hospital. This second batch of cases were admitted
to hospital on the 16th, 17th 18th, 1 9th, 22nd and 22nd August. On the
invitation of Lt.-Col. Bull, I.M.S., Staff Surgeon, I visited the Convent with a
view to seeing if we could in any way clear up the origin of this outbreak. The
Convent is beautifully clean, there are three dormitories, large, airy, upstairs rooms.
Ca s e s No . 1 a n d 9 c a me f r o m No . I d o r mi t o r y . Ca s e s 2 , 3 , 4 , a n d 5 f r o m No .
II. Cases 6, 7, 8, 10, 11, and 12 from No. III. On enquiry the nuns positively
stated that all the boarders had been in excellent health since their return from
the holidays on 31st May 1907. Nor had there been any sickness among the day
scholars or amongst the nuns themselves.
On further enquiry I discovered that one of the Goanese cooks had been
ill for a few days in the month of June. After some difficulty I obtained the
following facts regarding this man :—
About the 20th June he complained of pain in the side and, according to the
statement of the Hospital Assistant attached to the Convent, had fever, which
lasted for two days only. He continued to do work although in great pain and
losing flesh. At the end of June he asked for and obtained leave and departed
for Goa on the 3rd of July. He returned on the 31st July and resumed work. I
took his serum on 5th September 1907, and found that it reacted strongly
to B. typhosus up to a dilution of 1—100. I also took the serum of four other
cooks employed in the same kitchen, 2 Goanese and 2 Natives; their serum gave
a negative result in a dilution of 1-20.
The children all have the same food, and this food is prepared, in the same
cookhouse.
There are two mess rooms. Cases Nos. 1, 2, 3, 4, 5, and 9 used one mess,
cases 6,7, 8, 10, 11,12 the other.
21
They are not all in the same classes and the cases were dotted over the
three dormitories.
Deducting four days from the date of admission to hospital from the first
three cases, i.e., time ailing before detected, gives the 17th July as the day of
commencement of the disease and about the 1st of July as the day of infection.
The other two cases, 4 and 5, had also been ill for at least five or six days
before admission ; this would give 20th and 22nd July as the day of commence-
ment of disease and the day of infection as 2nd or 3rd of July.
The day of infection in Case No. 6 shown as admitted on 11th August is
more difficult to discover.
The nuns state that on 11th August this child was treated for " fever, " but
she was not admitted to hospital till 15th August 1907.
She was removed from the Convent on 16th August 1907 by her friends.
There are three suppositions possible as regards this case.
I. She was removed from the Convent within a day or two of being taken
ill, the diagnosis was not confirmed by Tidal test ; therefore her disease may
not have been enteric. I have made enquiries and find that this child was very
seriously ill at her home in khandala for one month after her return. I think,
therefore, that this was a true case of enteric.
II. Case No. 5 was ill for some days before admission to hospital. She
used the same latrine as Case 6, and it is possible that Case 6 was thus infected
although they used different messrooms and slept in different dormitories.
III. The cook, B. S., returned to duty on 31st July ; this child, No. 6, although
out of sorts on 11th August, was not admitted to hospital until 15th August. It is
quite possible that she was infected by contaminated food on 1st August and
developed the fever after a shorter incubation period than the others.
The other cases Nos. 7, 8, 9, 10, 11,12 all went sick, 17, 18, 19, 20, 23 and
23 days after the return of the Goanese cook.
In my opinion, therefore, the Goanese cook passed through a fairly severe
attack of enteric fever between June 20th and July l0th ; he contaminated the
food of the children in the first batch of cases 1 to 5 about July 1st before his
departure.
Case 6 is a contact case or a case with short incubation period, and the
second batch of cases 7 to 12 were due to contamination of the food after the
return of the cook on 31st July.
The last case of the second batch was admitted to hospital on the 22nd of
August ; up to the 16th of September there have been no fresh cases.
I have examined the fæces and urine of the cook, B. S., daily from the
8th September, but so far without finding any enteric bacilli ; he is, therefore,
not infective at present. This is shown by the fact that there have been no
22
fresh cases since the last batch which were infected during the first week
of August.
Statement of Enteric cases at the Convent Girl School, Poona,
11th September 1907.
No.
Names.
Age.
Caste.
Date of
admission.
Date of
discharge.
REMARKS.
*1 Daisy, R.
14 European
21st July
1907.
*2 Annie, F.
10
Do.
22nd July
1907.
*3 Josephine, C.
8 Native Christian
Ditto.
*4 Filamina, F.
7 European
25th July
1907.
*5 Helen, Roberts
7 Eurasian
28th July
1907.
†6 Nathaline, D.
8 Native Christian 11th August
1907.
16th August
1907.
Proceeded to Khan-
dala.
†7 Augollo, F.
7
Do.
16th August
1907.
17th August
1907.
Went to her home in
Poona.
†8 Christoline, D.
10
Do.
17th August
1907.
Ditto.
Ditto.
*9 Mary, N.
14
Do.
18th August
1907.
† 1 0 Mary, F.
12
Do.
19th August
1907.
19th August
1907.
Went to her home in
Poona.
*11
Mary, F.
12
Do.
22nd August
1907.
†12 Juauha, P.
15
Do.
Ditto. 27th August,
1907.
Proceeded to Bombay.
* Diagnosis confirmed by Widal reaction.
† D i a g n o s i s n o t c o n f i r m e d .
Cook B. S., age 21 years, reported sick on 20th June 1907.
Proceeded to Goa on 3rd July 1907.
Returned to duty on 30th July 1907.
Widal reaction, positive 1—100 dilution on 1st September 1907.
" " " o n 1 — 1 0 , 0 0 0 " o n 8 t h O c t o b e r 1 9 0 7 .
NOTE.—Cook B. S. was doing his duty while sick from 20th June 1907 until he left for Goa on the 3rd
July 1907.
23
V.—EVIDENCE SHOWING THAT ENTERIC FEVER IS CON
- T R A C T E D B Y O R D E R L I E S W H I L S T I N A T T E N D A N C E O N
PATIENTS.
During the course of the enquiry we obtained evidence to show that nursing
orderlies contracted the disease and passed through a typical attack of enteric
fever. At Poona nine men attended a class for instruction as nursing
orderlies on patients suffering from enteric fever ; out of this number three men
acquired the infection and one died. The cases were all proved to be enteric
fever by blood examination, and from the bile of the case which ended fatally a
pure culture of B. typhosus was obtained. One of the men had been twice
inoculated recently.
The following table gives the details of the outbreak:—
Number of men attending
the cases.
Date of
appointment.
Date of
discharge.
Date on which men
were admitted to
hospital for
enteric.
REMARKS.
Nine.
19th May 1907. 1. 27th July 1907.
3
1 27th July
1907.
Remainder 12th
August 1907.
1 16th. Au-
gust 1907.
Died.
1 17th Au-
gust 1907.
Inoculated—
1 28th March
1907.
2 22nd April
1907.
The above observation shows that the danger of becoming infected whilst
attending a case of enteric fever is considerable. In this case three out of a
total of nine became infected, 33.3 per cent. Apart from men who develop a
typical attack of enteric a number of men appear to become infected whilst in
attendance on cases but show no sign of disease. This class of individuals is
particularly dangerous, because some of them become " chronic bacilli carriers "
and sources of infection. We proceed next to consider this question in detail.
VI.—EVIDENCE SHOWING THAT ORDERLIES ON ENTERIC
FEVER CASES BECOME " BACILLI CARRIERS " WITHOUT
HAVING PASSED THROUGH AN ATTACK OF THE DISEASE.
At Kasauli we made a very careful bacteriological examination of the urine
and fæces for a prolonged period of four enteric fever orderlies who had finished
24
their course and were returning to their regiments. None of these men had ever
suffered from a typical attack of enteric fever. The result of this examination
showed that two of these men were excreting B. typhosus in their fæces.
This observation is of great importance, because the rule is that after six
months' duty as orderlies the men return to their regiments and a fresh supply
is sent, and as these orderlies are not submitted to a complete bacteriological
examination they must on their return to regimental duty increase the number of
" bacilli carriers " in the various units of the British troops in India.
The following table shows the result of the examination of the urine and
fæces of the enteric fever orderlies at Kasauli:—
Name.
Regiment.
Date of
observation.
B. TYPHOSUS IN
Widal
reaction.
Fæces.
Urine.
1. Private 7156 W.
. Bedford, A.
Coy.
18th August
1907 to 15th
October 1907.
—
—
Negative.
2. Private 3835 J.
.
R. F. A.
9th September
1907 to 16th
October 1907.
—
—
Ditto.
3. Private 6956 V.
.
R. Sussex
7th October
1907 to 10th
October
1907.
—
—
Complete
1—40.
11th October
1907.
+
22nd October
1907.
++
4. Private 7635 O.
. Bedford, F.
Coy.
5th October
1907.
+
+
22nd October
1907.
+
—
In addition to the enteric fever orderlies at Kasauli we discovered at Meerut,
whilst examining a large number of healthy soldiers, a man who was excreting
B. typhosus in his fæces. This man had no previous history of having passed
through an attack of the disease, but had acted as an orderly on enteric fever
cases. As already mentioned, the unit in which this man was serving at Meerut
supplied the majority of the enteric fever cases which we had an opportunity of
observing. Further particulars of this are given on pages 17 and 18 of this report.
25.
VII.—DIAGNOSIS OF ENTERIC FEVER.
In the prevention of enteric fever a correct diagnosis is a matter of supreme
importance. Should a slight or anomalous case pass unrecognised, it would
obviously prove a serious source of infection. This is illustrated in the case of
the epidemic at the Convent school, Poona, described above. Such a case
might show very few signs of disease but still be excreting the bacilli in enormous
numbers ; hence the important question arises, What is the best method for the
diagnosis of enteric fever? The serum agglutination test (Widal reaction) has
been very generally employed up to the present. If it is carried out with care,
the results are quite satisfactory ; but it is necessary to bear in mind the fallacies
that may creep in.
To obtain a standard to work on, we have carried out the serum agglutina-
tion test (Widal reaction) with the blood of a large number of apparently healthy
European soldiers, including those who had been inoculated against enteric fever
or passed through an attack of the disease recently. Also the blood of a number
of healthy Natives was examined.
The following statement shows the result of the examination of the blood by
the serum agglutination test (Widal reaction) of apparently healthy European
soldiers :—
Widal reaction in apparently healthy individuals.
European Soldiers.
(a) Not inoculated. No history of enteric. Total examined= 416.
No reaction
. . . . . . . . 166=39.8 per cent
Incomplete 1—10 dilution . . . . .
. 76=18.2 „
Complete reaction 1—10 „
. . . .
. . 97=23.3 „
Ditto 1—20 „
.
. . .
. . 64=15.3 „
Ditto 1—40 „
. . . . . . 13=3.1
„
(b) Inoculated (recently). Total examined=28.
No reaction .
. . . . . . . . .
3=10.7 per cent.
Complete 1—10 dilution . . . . . . .
6=21.4 „
Do. 1—20 „
. . . . . . . 12=42.8 „
Do. 1—40 „ .
. .
. .
. .
3=10.7 „
Do. 1—80 „
. . . . . . .
1=3.5
„
Do. 1—160 „
. .
. . . . .
3=10.7 „
c) Convalescent enterics (recent). Total examined=137.
Incomplete 1—10 dilution . .
. .
. . . 21=15.3 per cent.
Complete 1—10 „
.
. . . . . . 33=24.8 „
Do. 1—20 „ .
. .
. . . . 35=25.5
„
Do. 1—40 „ .
.
. . . . . 30=21.8
„
Do. 1—80 „
.
. .
.
. . . 15 =1.9
„
Do. 1—160 „
. . .
. . . .
1 = . 7 „
Do. 1—160 „
over
. .
.
. . .
2= 1.4
„
26
Native Followers. Total examined =111.
No reactio
.
.
.
.
.
.
.
.
.
.
26=23.4 per cent.
Incomplete 1—10 dilution
.
.
.
.
.
.
.
24=21.6
„
Complete 1—10 „
.
.
.
.
.
.
40=36.03 „
Do.
1—20 „
.
.
.
.
.
.
.
21=18.9
„
Native Children (Gurkhas). Total examined=21.
(7 to 12 years of age.)
No reaction .
.
.
.
.
. .
.
.
.
2= 9.5 per cent.
Incomplete 1—10 dilution
.
. .
.
.
.
.
2= 9.5
„
Complete 1—10 „
.
.
. .
.
.
.
10=47.6
„
Do.
1—20 „
.
.
.
.
.
.
.
6=28.5
„
Do. 1—
40 „
.
.
.
.
.
.
.
1 =4.5
„
Native Children (Gurkhas). Total examined=71.
( 7 to 14 years of age. )
No reaction .
.
.
.
.
.
.
.
.
.
25=35.2 per cent.
Incomplete 1—10 dilution .
.
.
.
.
.
.
7=9.8
„
Complete 1—10 „
.
.
.
. .
.
. 15=21.9
„
Do. 1—20 „
.
.
.
.
.
.
.
17=23.9
„
Do. 1—40 „
.
.
.
.
.
.
.
2= 2.8
„
Do. 1—60 „
.
.
.
.
.
.
.
4=5.6
„
Do. 1—120 „
.
.
.
.
.
.
.
1=1.4
„
The results show that a reaction in a dilution of 1 in 40 either for natives or
Europeans cannot be taken alone as positive evidence of the existence of an
infection by the B. typhosus. Comparing the results in Europeans and natives
it is seen that the percentage of complete sedimentations in 1 in 2 0
d i l u t i o n s i s
18 in natives (adults) as compared with 3 in Europeans (adults); hence the
necessity of using higher dilutions when the test is being carried out with
the blood of natives. The method which gives more accurate and certain
results is that of cultivating the bacillus from the blood-stream. Formerly the
technique of this procedure was very elaborate ; very recently, however, improved
methods have been introduced which have greatly simplified this investigation.
More particularly the method introduced by Conradi has been found to be
specially useful. Conradi's medium is composed of bile, peptone and glycerine,
but bile alone is said to act equally well. The medium is sterilised in the auto-
clave, no filtration being necessary. In practice we have put this medium in
vaccine bottles of 30 c.c. capacity, about 20 c.c. of medium in each bottle.
The bottle is closed with a rubber cap, which is sealed with paraffin. These
bottles can be very conveniently sent to hospitals for the collection of blood.
The operator has merely to remove with aseptic precautions 5 c.c. of blood in a
syringe from a vein at the bend of the elbow, and then pass the needle of the
syringe through the rubber cap and eject the contents into the bile bottle. The
paraffin is melted and the hole closed. The bottle is labelled and returned to the
laboratory where it may require to be incubated, but, as a rule, this is unneces-
sary, as the organism incubates on the journey. A few drops of the contents of
the bottle are plated on Drigalski plates and incubated at 37°C. and next day
the colonies are examined and tested. By this procedure we recover the germ