NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
16
TABLE III.— Showing case-mortality, average duration, etc. (excluding tuber-
cular cases).
Fatal cases.
Cases lasting
over 60 days.
Average duration
of remaining cases.
Cases showing one or
more previous admissions
to hospital for dysen-
tery and diarrhœa.
Bacillary cases.
42.8 p. c.
25 p. c.
27 days.
42.8 p. c.
Amœbic cases .
11.7 p. c.
15.5 p. c.
26
,,
50 p. c.
All other cases
10.4 p. c.
3.5 p. c.
22.7 ,,
34.2 p. c.
In most cases the disease ran an afebrile course. In neither bacillary nor
amoebic cases was any rise of temperature recorded during the stay in hospital.
Of the remaining cases, in five the temperature was slightly raised (99º-100º)
during the first day or two of illness.
In one case, (No. 263), the patient had been admitted to hospital for fever
(temperature 102.4°) eight days previously to the onset of dysenteric symptoms.
In another case there was a paroxysmal rise to 103.8° on the evening of the
second day of illness, the temperature being normal next morning and so
remaining thereafter.
The tongue showed no characteristic change and was generally remarkably
clean. In some cases there was a slight white coating, in others the tongue
showed a red raw appearance without fissures or ulcers.
The stools generally numbered 2-5 during the 24 hours in mild cases and
10-20 in severe cases at the height of the disease; the largest daily number
recorded in any case is 30. Griping and tenesmus were not invariably present
and were seldom severe.
There was often remarkable freedom from tenderness on pressure of the
abdomen, even in severe cases which post-mortem showed extensive ulceration.
When present, this symptom was generally most marked over the sigmoid
flexure or the cœcum.
In the more chronic cases thickening of the colon could sometimes be made
out on palpation.
In no case was there marked pain, tenderness or enlargement of the liver.
The bacillary cases showed entire freedom from complications.
17
Of the amœbic type of the disease œdema of the feet occurred in two
cases, one of which ended fatally, while the other recovered. Among the cases
"of uncertain orign" œdema of the feet occurred in five, all of them ulti-
mately fatal.
In one chronic case (No. 23) the patient complained of migrating pains
in the joints. After six days the pain became limited to the knee-joint from
which it finally disappeared a week later. The pain in the joints was not
accompanied by any appreciable swelling; its relation to the dysentery seems
uncertain.
(d) Blood examination.
The following tables show the results of blood-counts made in some of the
cases:—
TABLE IV.— Blood counts in bacillary cases.
Case
No.
Period of
examination.
Red cells
per c. m.m.
White cells
per c. m.m.
Polynuclears
p. c.
Lymphocytes
p . c
.
Large
mononuc-
lears.
p. c.
Eosinophiles
p. c.
REMARKS.
214
2nd day (10th
admission)
6 5 t h d a y
3,950,000
9,800
66.2
25.8
7.3
0.7
Severe chronic case with much wasting:
œdema of head, hands and feet. Tender-
ness of descending colon and sigmoid.
Three injections 20 c. c. anti-dysenteric serum
given at intervals of 2 and 5 days. Died.
Post-mortem : large intestine œdematous
and infiltrated; extensive ulcers; 2 ankylos-
toma duodenale found.
. .
2 5 , 6 0 0
74.6
23.0
1.6
0.8
67th „
...
44,780
69.3
28.2
1.3
0.2
69th „
...
18,920
56.7
39.2
3.9
0.2
71st „
...
25,720
77.1
21.8
0.7
0 . 4
73rd „
...
23,680
72.7
24.6
2.6
0.1
76th „
. . .
22,080
46.3
48.4
4.8
0.5
260
3rd day
...
8 , 9 0 0
74.8
18.3
6.2
0.7
1st admission: mild case. Recovered.
15th „
...
5,520
67.6
27.1
3.9
1.4
262
2nd day
.
...
6,920
79.4
17.0
3.0
0.6
1st admission: mild case. Recovered.
264
5th day
.
...
7,660
58.3
38.0
3.3
0.4
1st admission: mild case. Recovered.
18
TABLE V.— Blood-counts in amœbic cases.
Case
No.
Period of
examination.
Red cells
per c. m.m.
White cells
per c. m.m.
Polynuclears
p. c.
Lymphocytes
p. c.
Large
mononuc-
lears.
p . c .
Eosinophiles
p. c.
REMARKS.
19
D 2
35 2nd day .
.
...
9,960
64.3
30.6
4.6
0.5
7th admission : mild case. Recovered.
141 2nd day .
.
...
9,720
61.9
33.8
2.7
1.6
1st admission : chronic, severe case. Recov-
ered.
2 months later .
...
6,200
75.2
21.4
3.2
0.2
161 1st day .
. 3,642,400
7,160
57.0
38.0
4.0
1.0
1st admission : moderately severe. Recovered.
(oxyuris and asearis ova).
239
5th day .
.
4,387,500
7,900
62.6
24.1
9.9
3.4
2nd admission : moderately severe. Recovered.
37th „ .
.
4,563,333
11,600
69.9
22.9
4.7
2.5
243 15th day .
.
4,562,000
10,960
71.4
20.7
4.2
3.7
3rd admission : severe. Died. Post-mortem :
extensive thickening and ulceration of colon.
3 months later .
. . .
8,970
68.9
29.1
1 . 2
0.8
244 10th day .
. 3,714,700
16,580
74.3
14.4
6.0
5.3
1st admission : severe. Died. Post-mortem :
congestion and ulceration colon. One anky-
lostome in duodenum.
245 15th day .
.
4,919,200
12,320
48.5
37.0
10.0
4.5
4th admission: mild. Recovered.
250 1st day .
.
...
7,560
63.6
30.1
5.8
0.5
2nd admission : chronic. Recovered (anky-
lostoma ova).
After 2 months
...
7 , 4 0 0
70.8
26.0
2.5
0.7
251 2nd day .
.
...
8 , 7 4 0
71.2
22.3
5.7
0.8
1st admission : mild. Recovered (anky-
lostoma ova).
255 4th day .
.
...
11,000
78.6
1 7 . 8
2.6
1.0
2nd admission : moderately severe. Recovered
(ankylostoma ova).
8th „ .
.
. . .
11,400
66.5
30.5
2.7
0.3
TABLE VI.— Blood-counts in cases other than bacillary or amœbic.
Case
No.
Period of
examination.
Red cells
per c. m.m.
White cells
per c. m.m.
Polynuclears
p. c.
Lymphocytes
p. c.
Large
mononuc-
lears
p . c .
Eosinophiles
p. c.
R E M A R K S .
2
2nd day
...
11,140
60.1
33.7
5.1
1.1
2nd admission: mild. Recovered.
4
3rd day
3,158,350
5,140
59.2
35.3
5.0
0.5
2nd admission: chronic, severe. Died. Post-
mortem: thickening, irregular ulcers of colon.
13
...
. . . 8,280
73.1
24.8
1.9
0.2
3rd admission: chronic, severe. Died. Post-
mortem: extensive ulcers of colon (11 anky-
lostomes).
49
...
...
3,280
60.3
37.6
1.7
0.4
3rd admission, moderately severe. Reco-
vered.
... ...
5,740
69.3
27.7
2.3
0.7
74
...
...
9,740
69.7
2 6 . 4
3.4
0.5
2nd admission: severe, chronic. Died. Post-
mortem: extensive ulcers colon (anky-
lostomes).
123
1st day
5,065,000
10,000
65.5
2 7 . 0
4.5
3.0
1st admission: mild. Recovered.
163 1st day readmis-
sion.
...
5,800
64.5
30.5
3.5
1.5
2nd admission: mild. Recovered. (anky-
lostoma ova).
197 1st day readmis-
sion.
. . . 6,840
66.4
26.0
5.8
1.8
2nd admission: mild. Recovered.
231 6th day readmis-
sion.
. . . 9,740
68.7
25.3
5.6
0.4
2nd admission: mild. Recovered (anky-
lostoma ova.)
20
Case
No.
Period of
examination.
Red cells
per c. m.m
White cells
per c. m.m.
Polynuclears
p . c .
Lymphocytes
p. c .
Large
mononuc-
lears
p . c .
Eosinophiles
p . c .
R E M A R K S .
232
2nd day
4,330,000
8,200
53.0
29.0
10.4
7.6
2nd admission: mild. Recovered.
237
5th day
. . .
6,400
79.0
9.5
5.5
6.0
1st admission: mild. Recovered.
246
. . .
4,800,000
6,820
76.4
20.0
3.3
0.3
2nd admission: chronic, severe. Died. Post-
mortem congestion and old ulcers of colon
.
(ankylostomes).
247
3rd day
4,856,000
9,620
59.5
34.3
5.2
1.0
3rd admission: moderate, severe. Tenderness
right hipochondrium, temperature 103.8°,
2nd day: normal; thereafter liver not en
larged. Recovered (ankylostoma ova).
4th „
...
8,380
...
. . .
. . .
...
6th „
...
7,240
. . .
. . .
. . .
. . .
249
2nd day
4,442,300
5,800
69.0
24.0
6.1
0.9
10th admission: mild. Recovered.
253
2nd day
4,739,130
14,480
57.0
38.7
3.2
1.1
4th admission: mild, tenderness hypogastrium,
no enlargement of liver. Recovered.
3rd „
. . . 11,080
65.2
30.4
3.4
1.0
5th „
. . . 11,580
64.5
28.5
5.0
2.0
. . .
...
10,980
61.9
32.1
4.7
1.3
254
1st day
. . .
7,120
54.3
36.2
5.9
3.6
2nd admission: mild. Recovered (ankylos-
toma ova).
. . .
. . .
6,640
52.1
39.1
7.1
1.7
21
TABLE VI.— Blood-counts in cases other than bacillary or amœbic —contd.
TABLE VI.—Blood-counts in cases other than bacillary or amœbic. —concld.
Case
No.
Period of
examination.
Red cells
per c. m.m.
White cells
per c. m.m.
Polynuclears
p. c.
Lymphocytes
p. c.
Large
mononuc-
lears
p. c.
Eosinophiles
p. c.
REMARKS.
256
4th day
...
22,680
82.8
12.4
4.25
0.6
1st admission: mild, tenderness in hypogas-
trium, no enlargement of liver. Recovered.
5th „
...
13,280
. . .
...
...
...
6th „
. . .
16,500
. . .
...
...
...
7th „
...
11,340
71.0
21.8
6.8
0.4
257
5th day
...
8,660
65.3
32.5
2.0
0.2
1st admission: mild. Recovered (ankylostoma
ova).
259
6th day
...
8,140
77.5
15.3
6.0
1.2
2nd admission: mild. Recovered.
261
3rd day
..
12,980
69.8
26.4
3.2
0.6
4th admission: mild. Recovered (ankylostoma
ova).
263
11th day
...
7,000
5 8 . 8
37.2
3.8
0.2
2nd admission: mild. Recovered (ankylostoma
ova).
266
4th day
...
6,320
68.0
28.1
2.6
1.3
2nd admisson: mild. Recovered.
268
2nd day
. . .
6,980
...
. . .
. . .
. . . 7th admission: mild. Recovered.
22
23
It is noticeable that in some apparently uncomplicated cases of dysentery
a high and sustained lencocytosis may occur, although this is not the rule ;
this is in agreement with the findings during the dysentery enquiry in
Bombay.
(e) Agglutination reaction.
The following table shows the results of the agglutination test in bacillary
cases:—
TABLE No. VII. —Agglutination reaction in bacillary cases.
Case.
Period
of
disease.
Reaction on B.
Shiga with
dilution.
Reaction on B.
Flexner with
dilution.
Reaction on own
bacillus with
dilution.
REMARKS.
25
9th day
...
. . . 1 i n 20±
......
12th „
1 in 10 -
1 in 10 -
1 in 20 ±
......
27
5th day
...
...
1 in 10 -
......
12th „
. . .
...
1 in 10 -
. . . . . .
29
. . .
. . .
. . .
...
Blood not examined. Patient, an
epileptic suffering from mild
dysentery, died during a seizure
on day of admission.
34
4th day
. . .
...
1 in 80 +
......
12th „
. . .
. . .
1 in 40 +
......
41
6th day
...
...
1 in 80 +
. . . . . .
12th ,,
. . .
. . .
1 in 10 +
. . . . . .
115
26th day
...
. . .
1 in 80 +
......
128
...
. . .
. . .
...
Blood not examined. Bacillus re-
covered post-mortem only.
162
5th day
1 in 10 -
1 in 10 -
1 in 10 -
Mild case released from jail on
5th day.
198
9th day
...
...
1 in 10 +
. . . . . .
12th „
...
...
1 in 40 +
......
24
TABLE No. VII. —Agglutination reaction in bacillary cases —contd.
Case.
Period
of
disease.
Reaction on B.
Shiga with
dilution.
Reaction on B.
Flexner with
dilution.
Reaction on own
bacillus with
dilution.
REMARKS.
206
14th day
1 in 10 -
1 in 10 -
1 in 10 -
......
214
13th day
1 in 40 +
1 in 10 -
1 in 10 -
......
2 months
later.
1 in 10 -
1 in 10 -
1 in 10 -
Recurrence.
260
4th day
1 in 10 -
1 in 10 +
1 in 20 +
......
10th „
. . .
...
1 in 20 +
. . . . . .
14th „
1 in 10 -
1 in 10 +
. . .
......
262
1st day 1 in 10 -
1 in 10 -
. . .
......
10th „
1 in 10 -
1 in 10 -
1 in 10 -
......
264
2nd day
1 in 10 -
1 in 10 -
. . .
......
9th „
1 in 10 -
1 in 10 +
1 in 10 -
......
It is here apparent that, neither with stock cultures of B. Shiga and B.
Flexner, nor with the autogenous bacillus is a reaction obtained in any cases
with high dilutions of the serum.
Moreover, the agglutination test with stock cultures of " Shiga " and
" Flexner " strains was applied in 130 cases of dysentery in which no dysentery
bacilli were ultimately found and also in the cases of 40 prisoners who gave
no history of dysentery. The results are shown in the following tables
TABLE No. VIII. — Table showing the agglutination reaction on B. Shiga
and B. Flexner in 130 cases of dysentery from, which no dysentery bacillus
could be isolated.
Maximum dilution in which the blood-
serum agglutinated.
1
in
320
1
in
160
1
in
80
1
in
40
1
in
2 0
1
in
10
Nega -
tive 1
in 10.
(i) B. Shiga.
.
. .
1
0
4
1
8
15
101
(ii) B. Flexner
.
.
.
.
1
0
5
2
10
13
99
25
TABLE No. IX.— Table showing the agglutination reaction on (i) B. Shiga and
(ii) B. Flexner in 40 cases of prisoners who gave no history of dysentery.
Maximum dilution in which the blood-serum
agglutinated.
1
in
80
1
in
40
1
in
20
1
i n
10
Negative
1 in 10.
(i) B. Shiga .
.
.
.
. .
2
4
7
3
24
(ii) B. Flexner.
.
.
.
.
0
3
5
4
28
Thus the evidence from these cases, as far as it goes, is unfavourable to
the utility of the agglutination reaction as an aid in the diagnosis of bacillary
dysentery.
(f) Post-mortem examination.
Large intestine. —In all the fatal cases the large intestine showed marked.
congestion and there was generally considerable pulpy gelatinous thickening of
the submucosa. In a few instances, however, there was marked thinning and
atrophy of the intestinal wall, little but the serous coat being left in parts.
In some cases the surface of the mucosa was covered with a more or less
extensive diphtheritic exudate ; this was a marked feature in all of the six
fatal bacillary cases, neither did any of these bacillary cases show a state of
advanced ulceration.
In the cases generally, congestion varied from a mild hyperæ mia to the
most intense injection with hemorrhages, sometimes small and stellate or
punctate, sometimes forming extensive uniform dark, blue or black areas of
extravasation.
In many cases raised bluish gelatinous areas, oval or hemispherical in
shape, were found projecting from the mucous membrane, varying in size
from a pea to a large bean. Some of these presented single or multiple per-
forations at their apices through which a reddish or yellowish granular semi-fluid
material could be expressed.
Ulceration of the most varied types was found, small irregular superficial
erosions, areas of fine serpiginous ulceration or deeper ulcers with sloughy
bases, extending down to the muscularis or even to the serous coat ; some had
perpendicular, some undermined edges.
The cœcum and rectum were perhaps the favourite sites, but the
ulcers were not generally localised to a particular spot, and in many cases the
whole extent of the large intestine was covered with ulcers, old and recent.
In two cases, multiple spherical bodies with short pedicles and varying in
size from a pea to a marble, were found projecting from the mucous membrane E
26
of the rectum. One of these cases was " amœbic," the other was " of uncertain
orign."
The small intestine. —There was generally, in all cases of dysentery exa-
mined post-mortem, congestion of the lower part of the ileum, occasionally with
sub-mucous hæmorrhages ; the Peyer's patches were not especially involved.
In contrast to the tubercular cases, these dysentery cases showed, no ulcera-
tion of the ileum except in one instance, where there was slight superficial
erosion, confined to the lowermost four inches.
In some cases there was distinct atrophy of the wall of the small intestine.
The number of ankylostoma worms found post-mortem in any single case
was generally 1-5 and never exceeded 20. In no case could serious damage of
the gut be directly attributed to their presence.
The mesenteric glands. —The mesocolic glands generally showed more or
less distinct enlargement ; they were, as a rule, uniformly soft in consistence
and pale pink in colour ; in a few cases they showed deep congestion with
stellate capsular hæmorrhages and were plum-coloured on section.
In four cases, all " of uncertain origin," the liver was slightly enlarged
and fatty. The lungs in two cases, both " of uncertain origin," showed infrac-
tions, while in another case there was gangrene of the lung.
Otherwise there was a remarkable absence of complications.
In none of the six fatal amœbic cases could any amœbæ be detected in
stained paraffin sections of the ulcers. A detailed microscopic study of the
pathological material has not yet been completed.
(g) Bacilli of the dysentery group isolated.
In fourteen cases organisms were isolated whose ultimate reactions would
seem to establish their claim to inclusion within the group of the bacillus
dysenteriæ.
The differentiation of bacilli by means of their actions in fermenting
sugars presents, perhaps, peculiar difficulties in a warm climate, but in the
following description only such results of sugar fermentation experiments are
included as have been verified by repeated observations in each case.
All these bacilli have the following points in common. (i) On Conradi-
Drigalski medium they form fine transparent blue colonies ( i.e. they do not
form acid in lactose medium). (ii) Microscopically they are found to be short
rods, showing, as a rule, very active Brownian movement, without definite
progressive motility. (iii) They stain easily with methylene-blue or other aniline
dye but are Gram-negative. (iv) A transplant on an agar slope shows a fine
white filmy moist growth after 24 hours. (v) They form acid, but no gas in
glucose media.
Their further characteristics are set forth in the following table :—
Case No.
Sitmas milk.
Dextrin.
Maltose.
Mannite.
Indol.
Effects on rabbits.
25 Slight acid after 24 hours,
then alkaline.
No change . Slight acid . Acid . . + after 7
days.
2 c. c. of a 24 hours' broth culture intraperitoneally. Diarrhœa
with blood and mucus. Paralysis of hind legs. Death in
two days. Post-mortem : acute inflammation of colon.
27 No change. . . . Slight acid . No change . Acid . . + after 7
days.
Half of a 24 hours' growth on agar slope given intraperitone-
ally. Diarrhœa (blood and mucus). Paralysis of hind legs.
Death after 24 hours. Post-mortem: acute inflammation of
colon.
29 No change . . . No change . Acid . . Acid .
. + after 7
days.
Half of a 24 hours' agar growth intraperitoneally. Severe
diarrhœa (mucus) and wasting. Recovery.
34 Slight acid after 24 hours,
then alkaline.
Acid .
. Acid . . Acid . . + after 7
days.
Half of a 24 hours' agar growth intraperitoneally. Diarrhœa
(mucus and blood). Death after 24 hours. Post-mortem :
inflammation of colon.
41 No change .
. . No change . Slight acid . No change .
—
3 c. c. of a 24 hours' broth culture intraperitoneally. Severe
diarrhœa (mucus and blood). Wasting; recovery after 5
days.
115 Slight acid after 24 hours,
then alkaline.
No change . Slight acid . No change .
—
Half of a 24 hours' agar growth intraperitoneally. No diar-
rhœa. Death within 24 hours. Post-mortem : congestion
of colon.
128 No change .
. . Slight acid . Acid . . Acid . . + after 10
days.
3 c. c. of a 24 hours' broth culture intraperitoneally. Paralysis
of hind legs; diarrhœa. Death after 36 hours. Post-mortem:
extreme congestion of peritonæum.
27
TABLE X.—Showing distinctive reactions of the dysentery bacilli isolated.
Case No.
Sitmas milk.
Dextrin.
Maltose.
Mannite.
Indol.
Effects on rabbits.
162
Slight acid after 24 hours,
then alkaline.
No change . Acid .
. No change .
—
......
198
Slight acid after 24 hours,
then alkaline.
No change . Acid .
. Acid .
. + after 10
days.
4 c. c. of a 48 hours' broth culture given intraperitoneally.
Diarrhœa; death in 24 hours. Post-mortem: large intestine
inflamed, extreme congestion of abdominal vessels.
206
Slight acid after 24 hours,
then alkaline.
No change . No change . No change .
—
4 c. c. of a 48 hours' broth culture given intraperitoneally.
Diarrhœa: death within 24 hours. Post-mortem: colon in-
flamed, lymphyflakes on mucosa.
214
Slight acid after 24 hours,
then alkaline.
No change . Slight acid . Acid
. . + after 10
days.
4 c. c. of a 48 hours' broth culture intraperitoneally. Diarrhœa,
paralysis (?). Death within 24 hours. Post-mortem: colon
inflamed, abdominal vessels congested.
260
Slight acid after 24 hours,
then alkaline.
No change . Slight acid . Acid .
. + after 10
days.
3 c. c. of a 24 hours' broth culture intraperitoneally. Paralysis,
diarrhœa; death in 24 hours. Post-mortem: submucous hæ-
morrhages in colon and in bladder. Injection of peritonæum.
262
Slight acid after 24 hours,
then alkaline.
No change . Acid .
. Acid .
. + after 10
days.
3 c. c. of a 24 hours' broth culture intraperitoneally. Diarrhœa,
(mucus), weakness and emaciation. Died on 6th day, sub-
mucous hæmorrhages in cœcum; injection of peritonæum and
of bladder and tuneca vaginalis.
264
Slight acid after 24 hours,
then alkaline.
No change . No change . No change . + after 10
days.
3 c. c. of a 24 hours' broth culture intraperitoneally. Diarrhœa
(mucus blood). Wasting, death on 8th day. Post-mortem:
congestion of colon. Peritoneal injection.
28
29
The differences in the reactions of these different bacilli are very striking
and are hard of interpretation. The question as to whether such differences
depend upon mutations in the characters of one single species or are in them-
selves genuinely specific, still remains to be settled.
In any case it would seem that this type of bacillary infection is not
highly contagious.
These bacilli were isolated during the acute phases of the disease only and
repeated attempts to recover the bacillus from the stools of the cases during
convalescence and, later, while in the " post-dysenteric gang," met with no
success.
In none of the five fatal cases in which bacilli had been cultivated from
the stools during life were they recovered by cultivation from scrapings from
the ulcerated intestine made post-mortem . In one of these cases autopsy was
made within an hour of death.
On the other hand, in the single case (No. 128), in which dysentery
bacilli were cultivated from the scraping of an ulcer, the post-mortem had not
been made until 11 hours after death.
(h) The amœbæ met with.
Cultivation of amœbœ. —During the work of the dysentery enquriy in
Bombay it had been observed that amœbæ could, in a large proportion of ex-
periments, be cultivated from a great variety of sources, fæces, both dysenteric
and healthy, among others.
This experience was repeated at Hazaribagh ; in a series of 76 cases of
dysenteric stools planted on Musgrave's medium, in 74 were amœbæ found
growing. Moreover, amœbæ, apparently similar in type, were cultivated from
healthy stools and from samples of the jail water, taken both before and after
boiling.
In cultures from all these different sources it was noted that amœbæ were
often found growing in association with colonies of moulds and other conta
- m i n a t i n g o r g a n i s m s f r o m t h e a i r .
It was found, moreover, that uninseminated plates of Musgrave's medium
generally showed colonies of air organisms on their surface after standing for
two or three days at room temperature.
On examination of such colonies under the low power of the microscope, it
became evident that on some occasions amœbæ were growing in association
with these self-sown bacteria from the air.
In a series of experiments, details of which are given in the following
table, it was found that in 14 out of 36 such uninoculated plates, amœbæ
could be demonstrated.