NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
Germany such an individual is called Bazillenträger. In English the most
suitable equivalent is " bacilli carrier." These " bacilli carriers " have at some
time previously passed through an attack of enteric fever ; it may be an ordinary
severe attack or so mild as to have passed unrecognized. The detection of
these " bacilli carriers " is most important, as round them, probably, hinges the
whole problem of the prevention of enteric fever. Unfortunately their detec-
tion is an extremely difficult matter and requires for its successful accomplish-
ment specially skilled observers. Experience has shown that it takes several
months to train a worker to become really efficient in the detection of
B. typhosus in the excreta: for ordinary workers to express an opinion on the
presence or absence of B. typhosus in the fæces, particularly, is not only useless
but, as a rule, misleading. The difficulties are further increased on account, as
we shall see, of the very intermittent discharge of the bacilli in the urine and
fæces. In one case in which daily observations were made the urine remained
sterile for a month and then there was a sudden output of bacilli.
The observations recorded in the present report have been made chiefly
amongst British troops, but a certain number of cases of enteric fever amongst
Natives have been studied. That the disease occurs in Natives of India is
definitely proved. We have examined the urine and fæces of several Natives,
and found that they also continue to discharge the bacilli after freedom from
fever and all other signs of disease. Such individuals if employed in connection
with food supplies would be a source of danger.
A question of considerable importance, but one difficult to test by experi-
ment, is, whether the European is infecting the Native or vice versa? Certain
facts tend to support the former view. The incidence of the disease amongst
Natives in jails is low, whilst amongst Natives in contact with large European
communities with a large number of British troops it appears to be higher. We
are at present endeavouring to collect more precise details on this important
subject, and the results will be set forth in a future report.
III.—OBSERVATIONS ON PATIENTS CONVALESCENT FROM
ENTERIC FEVER.
The observations on convalescents were made at Kasauli, because it is a
large convalescent depôt for Northern India and supplied us with a considerable
amount of material for investigation. We have examined this year 86 convales-
cents and found ten excreting the bacilli either in the urine or fæces for periods
longer than six weeks after freedom from fever. If a convalescent continues to
excrete the bacilli for longer than six weeks, the German workers regard such an
individual as a " chronic bacilli carrier." So that in our observations we had
11.6 per cent. of " chronic bacilli carriers " amongst the convalescents. Some
8
of the patients still continue to excrete the bacilli, months after freedom from
fever.
Some of the observations on the urine and fæces were commenced on the
admission of the cases into hospital and kept up daily throughout the disease
and for several months after freedom from fever. We have thus accumulated a
large number of facts on which to base conclusions.
In regard to Natives of India we have examined the blood, urine, and fæces
of several cases of enteric fever in Natives which came under our observation at
Poona and elsewhere. It will be seen that they continue to discharge the
B. typhosus in the urine and fæces after all signs of the disease have dis
-appeared.
The results of the daily observations on the patients convalescent from
enteric fever, both Europeans and Natives, are shown in Table No. 1 of the Appen-
dix. Particular attention is directed to this table, as it is the record of numerous
observations which prove that a certain percentage of immune individuals har-
bour the parasite for a very long time.
In discussing the results obtained by the above-mentioned observations the
points may, for convenience, be considered under the following heads : —
(a) The number of bacilli excreted in the urine.—It will be seen from the
counts which are given in the table that in some cases the bacilli are excreted in
enormous numbers, as many as 100,000,000 in each c. c. of urine and the men at
the time showing no signs of illness. The urine in many cases is a pure culture
of the germ. The danger of such an individual infecting food supplies, etc., is
very great. He is acting as a reservoir of the parasite and he may continue to
do so for months.
(b) The marked intermittent character of the excretion of the B. typhosus in
the urine and fæces of patients.—This important fact has emerged in the course
of our observations. Its practical significance is very great, because if the
urine and fæces were examined once, twice or even twenty or more times during
the bacilli-free interval a wrong conclusion would be arrived at and a man still
infective would be returned to duty. The rule in Germany is to examine a case
three times after freedom from fever at intervals of ten days, and if he is found
free from bacilli at the last examination he is discharged from hospital. From
the above observations it is seen that this examination is not sufficiently
exhaustive. It becomes, therefore, a matter of great difficulty to determine
when a case is permanently bacilli free. In case No. 3 it will be seen that the
urine was examined on the 7th August 1907 and found to contain bacilli. It was
examined every day after that with negative results until 8th September 1907,
thirty-one days after, when bacilli again appeared. If such a case had been exa-
mined on any of the bacilli-free days he would have been regarded as permanently
9
free and discharged. This fallacy is to be carefully borne in mind by those
engaged in such investigations. The examination of the faces shows that the
discharge of bacilli has the same intermittent character. In case No. 7 the
fæces were examined on 12th and 13th August 1907 and the presence of bacilli
determined ; daily examination showed the absence of bacilli from the fæces until
the 29th August 1907, fifteen days after the last occasion on which it was found
Again, in case No. 12 the fæces were examined on 31st July 1907, and found to
contain bacilli and after that remained negative until 6th September 1907. Also
in case No. 3 the faces were found to contain B. typhosus on 6th August 1907
and remained negative till 21st October 1907, an interval of seventy-five days.
The most reasonable explanation of the intermittent character of the excretion of
bacilli in the urine and faces is that the urine in the urinary tubules becomes infect-
ed by a focus of bacilli in the kidney and the bacilli continue to cultivate them-
selves in the urine for a time, but are finally washed out by fresh uninfected urine.
When another focus again infects the urine the process is repeated. So long as
the bacilli in the focus are cut off from the urine a bacilli-free interval results. In a
certain number of cases infection of the urine never occurs. As regards the
occurrence in the fæces we know that the bile in cases of enteric fever
contains practically a pure culture of B. typhosus. The bile is infected by
bacilli lying in the deposits in the liver. The bile and its contained bacilli obtain
an exit into the external world viâ the intestinal tube in the fæces. All the
evidence is in favour of the liver and bile being the reservoir which supplies the
intestine with bacilli. So that the two great storehouses of the bacilli in the
" chronic carrier " are the urinary and biliary organs. It is noteworthy that the
bile and urine are both excellent culture media for B. typhosus and the bacillus
finds in these fluids far more favourable conditions for its development than it
does outside the body. As we shall see later, the extra-corporeal existence of
the parasite under natural Indian conditions is short as compared with that
inside the body of the host.
(c) The absence of the bacilli from the urine and fæces throughout the
whole course of the infection.—In case No. 8, Mrs. W., which developed in
Kasauli, a blood culture was made on 19th July 1907 and B. typhosus obtained.
Examination of the urine and fæces from 20th July 1907 to 20th September
1907 was made nearly every day and the bacilli never appeared on a single
occasion in either the urine or faces.
This was an example of a pure septicæmia throughout the whole course of
the disease and convalescence, and is of interest on that account. From the
point of view of prevention of the spread of the disease this case had no great
significance, because the bacilli were never voided into the external world at
all. They could only have escaped with the blood, e.g., by being taken up
by a blood-sucking insect.
I0
(d) The action of urotropine on bacilluria.—An important practical ques-
tion requires to be answered. Can urotropine be relied upon for the permanent
cure of typhoid bacilluria? The results of our observations have shown that we
cannot depend on urotropine for the permanent cure of bacilluria.
Urotropine or hexamethylene tetramine is soluble in water 1-1 with
alkaline reaction, in alcohol 90 per cent. 1 -8, almost insoluble in ether. It
acts by liberating formaldehyde in the urinary passages.
A study of cases Nos. 1, 2 , 4, 7, 12, and 14 in Table No. 1 of the Appendix
shows that although urotropine was given in full doses yet the bacilluria was
not in any way checked by its administration. Further, in case No. 3, S., to
whom no urotropine was given, the bacilluria ceased spontaneously and the
urine remained bacilli free for a long time. The same fact is observed in other
cases when the patients received no urotropine. The probable explanation of
the failure of urotropine to check the bacilluria permanently is, that the form-
aldehyde acts only on the urine in the urinary passages, but does not reach the
bacilli in the deposits in the substance of the kidneys. The practical conclusion
to draw from these observations is that urotropine cannot be regarded as an
effective agent for permanently destroying bacilli in the urinary organs.
(e) Those convalescent after enteric fever act as reservoirs of the
parasite.—We see from the above observations that a fairly high percentage of
the cases which recover from enteric fever continue to harbour the bacilli
although they themselves appear perfectly healthy. It is impossible by any
ordinary medical examination to say when a man is free from bacilli. As a
systematic examination of the fæces and urine of convalescents has hitherto not
been carried out in India and as our observations have shown that the bacilli
continue to be voided intermittently in the urine and fæces of a certain
percentage of convalescents for very long periods, there must be a considerable
number of such " carriers " scattered about in various units of the British Army
in India, and we have in this fact the explanation of the persistence of the
disease in spite of vigorous sanitary measures taken to destroy the germ in places
outside the human host. As we shall discuss later, the saprophytic existence of
the bacillus typhosus outside the human body under natural Indian conditions is
a short one. Hence we see that for its continued life a host is necessary, and it
finds in certain parts of the human body a nidus suitable for a prolonged exist-
ence. An epidemic of enteric fever is determined by bringing a " bacillus
carrier " in contact with some form of food supply. By ordinary sanitary
enquiry it is impossible to trace such an epidemic to its source. We see, there
-fore, the very important rôle which the " bacilli carrier " plays in the production
of epidemics in India.
We must regard flies, dust, milk, etc., as being merely channels of com-
munication of varying significance between the " carrier" and the uninfected
individual. Hence the great importance of concentrating attention on the-
" c a r r i e r , " w h e t h e r h e i s a s i c k m a n o r a p p a r e n t l y h e a l t h y , i n a l l m e a s u r e s f o r
the prevention of enteric fever.
We pass to consider next
—
IV.—THE EVIDENCE IN FAVOUR OF EPIDEMICS OF ENTERIC
FEVER BEING CAUSED BY THE " CHRONIC BACILLI
CARRIER."
In most epidemics of enteric fever it is difficult to show conclusively what is
the. source of infection.-
Up to the present in India there has been a good deal of mystery surround-
ing the persistence of this disease in Indian cantonments in spite of vigorous
sanitary measures. In the light of scientific research the mystery surrounding
the subject becomes dispelled and the whole question is placed on a sounder
basis.
The evidence brought forward in support of the statements in this section is
based on the results of scientific investigation. The blood, urine, and fæces of
a large number of apparently healthy people were examined several times, in
order to determine the presence or absence of a " carrier" amongst them. Hence
the observations may be regarded as being as complete as it is possible to make
them in the present state of knowledge.
A study of several epidemics was made to ascertain the source of the infec-
tion, and the results of this enquiry are stated below.
(1) An epidemic in a detachment of the Bedfordshire Regiment at
Kasauli. —During the month of August 1907 five cases of enteric fever occurred in
this detachment. Four of these were admitted into the Station Hospital, Kasauli,
and were proved by cultivations made from the blood to be infections caused by
bacillus typhosus. One man of this section left Kasauli on 31st July 1907 and
was amdmitted into hospital at Jhansi on 2nd August 1907 for enteric fever,
having, undoubtedly, become infected at Kasauli. So that five men of the
detachment of Bedfords acquired the infection about the same time in the same
place. The disease did not extend to any of the other units. We had, therefore,
to deal with an epidemic localised to one unit.
-
The cases occurred in two barracks, Nos. 12 and 13, in which the detach-
ment of the Bedfords was quartered. Each barrack is divided into four
wards. The cases did not occur in one of the rooms of the barrack, but each in
different rooms, so that there was no direct personal communication between the
patients. These two barracks were supplied with food from a common cook-
house and they had a common latrine and urinal.
C 2
I2
A careful sanitary inspection by the Senior Medical Officer was made to
determine the origin of the epidemic. As the cases were confined to this
detachment the general water and milk supply could be eliminated as factors in
the causation. It was considered that the men might have contracted the infec-
tion at one of the religious institutes. The evidence supporting this hypothesis,
however, was not very satisfactory. The source of the epidemic remained
obscure.
In order to determine scientifically the origin of the epidemic a systematic
examination of the blood, urine, and fæces of all the cooks and " contacts" of this
unit was made. The examination of the urine and fæes of each individual was
repeated at least twice. The result of this long series of repeated observations
proved that a cook of this detachment (Pte. 4805 G. W.) was excreting
bacillus typhosus in large numbers in his fæces. This man was in fact a
" chronic bacilli carrier. " None of the other contacts were found to be ex-
creting B. typhosus in the stools or urine.
The distribution of the disease suggested that the source of infection was in
the food supply of this unit. The disease did not spread from man to man in
one room. Had this been so it would have indicated that the infection was
spreading by direct personal contact. On the contrary, with the exception of
one room, not more than a single case occurred in each room. Hence the
working hypothesis, which agreed best with all the facts, was that some indivi-
dual dealing with the food of the unit in the cookhouse was a " chronic
-carrier. " The detection, therefore, of a " carrier" (Pte. W.) in the cookhouse
fully substantiated this hypothesis and satisfactorily explained the origin of the
epidemic which would otherwise have remained in complete obscurity. An in-
teresting feature in this epidemic was that the Native element could be completely
eliminated as no Natives are employed in the cookhouse of the unit.
The information of the discovery of this " chronic bacilli carrier " was given
to the Senior Medical Officer, who at once segregated him. The result was that
no further case of enteric fever occurred in this unit. If this man had continued
at duty in the cookhouse it is almost certain he would have infected another
series of men. As we have observed in other cases, this man excretes the bacilli
very intermittently. If we had been content with one examination of the fæces
only, he would not have been. detected. Our previous experience, however,
indicated the great importance of making repeated examinations.
A careful enquiry was made into the past and present history of this"
bacilli carrier." No. 4805 Private G. W., E. Company, Bedfordshires, has a
total service of thirteen years and eight months and eleven years eight months
in India. An examination of his medical history sheet shows that he has no
entry for enteric fever, but at Ferozpore he was in hospital seventy days from
13
31st December 1897 to 10th March 1898 for 24 a Ague described as " severe."
He was admitted to the Mooltan Hospital for forty-two days for 799
Abscess, described as " severe, " from 23rd May to 3rd July 1899. The next
entry is at Dalhousie for 24a Ague for twenty-three days, from 3rd October
to 25th October 1900, and is described as " mild. " The only other admis-
sion after this is eleven days for 143 a Conjunctivitis catarrhal acute at
Mooltan from 1st to 11th March 1991. He never acted as a nursing orderly.
At present he looks the picture of health and has no sign of disease. In
reviewing this case the occurrence of a past enteric infection has to be
considered. The entry of seventy days for ague of a severe character raises
the question as to whether or not this was an unrecognised typhoid infection.
The admission into hospital a year later for severe abscess is noteworthy, as
suppurations following typhoid infections are not very uncommon and the pus is
often found to contain a pure culture of typhoid bacilli. If the infection was
enteric fever, he has been a " bacilli carrier " since 1898, nearly ten years. His
Widal reaction to Bacillus typhosus is similar to that found in many convalescents.
The following table shows the result of the Widal reaction to Bacillus
typhosus and the presence or absence of Bacillus typhosus in the fæces and urine
of No. 4805 Private G. W., E. Coy., 1st Bedford Regiment :—
Date.
Number, rank, name
and
Regiment.
WIDAL REACTION TO BACILLUS
TYPHOSUS.
BACILLUS TYPHOSUS IN
20
40
Fæces.
Urine.
August 1907 G. W., of 1st Bedford
Regiment, E. Coy.
17th..
......
+
—
...
—
18th .
.
......
...
...
—
. . .
19th .
.
. . . . . . . . .
. . .
* + +
—
25th
.
......
...
. . .
+
—
27 th.
.
......
...
. . .
. . .
—
28th
. .
......
. . .
...
— —
*For expl anat i on of si gns used, vi de page 49, Appendi x of t hi s r epor t .
14
Cate.
Number, rank, name
and
Regiment.
WIDAL REACTION TO BACILLUS
TYPHOSUS.
BACILLUS TYPHOSUS IN
20
40
Fæces.
Urine.
August 1907
29th .
......
...
...
—
—
30th .
.
......
...
. . .
— —
31st .
. . . . . .
. . . ...
++
—
September
1st .
.
......
. . .
. . .
. . .
—
2nd.
.
. . . . . .
. . .
. . .
—
—
3rd .
, .
......
. . .
...
+
—
October
2nd .
.
......
. . .
. . .
—
. . .
10th.
......
. . .
...
—
. . .
November
1st .
......
...
. . .
+
. . .
The following table shows the cases of enteric fever which occurred in the
detachment of the 1st Bedford Regiment at Kasauli and Jhansi and the result of
the examination of the blood :—
Serial No.
N umber, rank, name
and
Regiment.
Date of admission
to
hospital.
Date of observation.
Bacillus typhosus in
blood.
1
8367 Pte. B. F., 1st Bed-
fords.
6th August 1907
12th August 1907
+
2
8173 Pte. H. I., 1st Bed-
fords.
10th
do.
20th
do.
+
3
7993 Pte. J. D., 1st Bed-
fords.
12th
do.
. 14th
do.
+
4
8089 Pte. G. S., 1st Bed-
fords.
18th
do.
. 20th do.
+
5
Pte. F., 1st Bedfords
2nd do.
at Jhansi.
Not examined.
15
The following table shows the result of the examination of the blood, urine,
and fæces of the healthy men (cooks, enteric orderlies and contacts) of the 1st
Bedfords at Kasauli :—
Designation of
healthy
individuals.
Total
No.
Total
exam-
ined.
Widal reaction to Bacillus
typhosus.
BACILLUS TYPHOSUS IN
Urine.
Fæces.
Cooks .
..
5
5
1 Man complete 1—80
5 Negative
4 Negative.
2 Men
,,
1—20.
1 Positive.
1 Man „ 1—10.
1 ,, no reaction.
Nursing Orderlies
3
3
1 Man complete 1—10
3 Negative
3 Negative.
2 Men no reaction.
Enteric Contacts
34
34
2 Men complete 1—40
34 Negative 34 Negative.
8 ,, ,, 1—10.
24 „ no reaction.
The following table shows the characters of the organism separated from
the stools of Private No. 4805 W. G., E. Coy., 1st Bedfords :—
M i c r o s c o p i c c h a r a c t e r s .
O r d i n a r y t r o t h .
O r d i n a r y a g a r .
P c t a t o .
L i t m u s m a n n i t e .
L i m u s m i l k .
L i t m u s l a c t o s e n u t r o s e .
L i t m u s g l u c o s e n u t r o s e .
L i t m u s w h e y .
N e u t r a l r e d a g a r .
I n d o l r e a c t i o n a f t e r 1 4 d a y s .
S e r u m r e a c t i o n . T i t r e s e r u m 1 — 8 , 0 0 0 .
S t o c k B a c i l l u s t y p h o s u s ( B e r l i n ) .
A c t i v e l y m o t i l e r o d s ; g ' a m n e g a t i v e .
U n i f o r m t u r b i d i t y ; n o s c u m .
G o o d w h i t i s h t r a n s l u - c e n t g r o w t h .
M o i s t g r o w t h .
Re d .
N o c l o t t i n g ; r e d .
N o c h a n g e .
Red.
R e d .
N o c h a n g e . N o g a s .
N o n e .
C o m p l e t e 1 — 8 , 0 0 0 .
B . t y p h o s u s . ( P r i v a t e W . )
A c t i v e l y m o t i l e r o d s ; g r a m n e a t i v e .
U n i f o r m t a r b i d i y ; n o s c u m .
G o o d w h i t i s h t r a n s l u - c e n t g r o w t h .
M o i s t g r o w t h .
Re d .
N o c l o t t i n g ; r e d .
N o c h a n g e .
R e d .
Red.
N o c h a n g e . N o g a s .
N o n e .
C o m p l e t e 1 — 8 , 0 0 0 .
16
The result of this investigation has thrown a flood of light on the source of
this epidemic. It would have been impossible by ordinary sanitary inspection
or enquiry to have arrived at a correct conclusion. It further demonstrates
that the " chronic bacilli carrier " can produce an epidemic of enteric fever.
(2). Two cases of enteric caused by a " chronic carrier. " —In July 1906 a
boy (Joseph T.) was admitted to the Station Hospital, Kasauli, from the married
quarters, suffering from enteric fever. Later in the month a next-door neighbour
of this family, Mrs. C., was admitted for enteric fever. In both cases the
Bacillus typhosus was recovered from the fæces. In order to trace the source
of these two cases the blood, urine, and fæces of all the members of the T. family
were examined. The result of this investigation showed that Mrs. T., the mother
of the first patient, was excreting bacilli in her fæces. The Widal reaction to
Bacillus typhosus was complete in 1 in 80 dilution. Mrs. T. was a " chronic
bacilli carrier."
A careful enquiry was made into her previous history. She had never
passed through a typical attack of enteric fever. About two months previously
she had been sick for a few days, her symptoms being diarrhœa and fever.
At the time of examination she looked perfectly healthy.
The following table shows the result of the examination of blood, urine, and
fæces of the abovementioned cases of enteric fever :—
WIDAL REACTION.
BACILLUS TYPHOSUS IN
N A M E .
Age. Clinical
diagnosis.
Bacil
lus typhosus.
Bacillus
paratyphosus
B.
Fæces.
Urine.
REMARKS.
T. J., son of Sergeant
T. , Royal Welsh
Fusili ers.
3 1 0 / 1 2
Enteric
1—100, com-
plete posi-
tive, 2nd
July 1906.
. . .
Present, 3rd
July 1906.
Absent, 5th
September
1906.
Absent, 10th
August 1906.
Absent, 5th
September
1906.
C., Mrs., wife of
Sub-Conductor C.,
S. & T. Corps.
40 Enteric
1—200, com-
plete posi-
tive, 14th
July 1906.
Negative, 14th
July 1906.
Present, 20th
August 1906.
Absent, 20th
August 1906. Mrs. C. lived
in the next
quarters to
Mrs. T. "ba-
cilli carrier,"
and associat-
ed with her.
Absent, 30th
August 1906.
Absent, 20th
August 1906.