PUBLIC RECORD OFFICE
Reference :-
C.O. 885
ALLY WITHOUT PERMISSION OF THE BE REPRODUCED PHOTOGRAPHIC- COPYRIGHT PHOTOGRAPH-NOT TO
23 PUBLIC RECORD OFFICE, LONDON
196
the pericardium. Most of the viscera were congested, especially the liver and kidneys, but the striking feature of the case was that the pancreas was practically destroyed, being acutely hæmorrhagic and pulpy.
(3) C.T., male, aged 8 years, black. Was suddenly seized with vomiting He then had convulsions, became at 6.30 a.m. on 18th December, 1914. unconscious, and remained so till death. At the post-mortem examination the following were the only important departures from the normal noted: small patches of broncho-pneumonia scattered over the lungs; congestion of the stomach, with a small petechial patch towards the cardiac end; several round worms (ascarides) were present in the intestines, but, as in the last case, which occurred the previous day, the pancreas was barely recognizable, consisting of a mass deeply infiltrated with blood and very soft.
The interest of these two cases consists not merely in the fact of their exhibiting a condition of acute hæmorrhagic pancreatitis and of their occurring within twenty-four hours of each other, but in the fact that they This condition has been were both reported as cases of "vomiting sickness."
noted before in a small percentage of cases of this disease.
The interest is enhanced by the fact that one of the cases occurring at Montego Bay in the middle of an outbreak of the so-called vomiting sickness in February, 1915, showed the same post-mortem signs in the pancreas.
(4) I.P., male, white. Had suffered for many months with pain referred mainly to the right side of the abdomen. He was an Inspector of Pelice, and had been able to continue at his work in spite of the pain. He had been to England, where appendicitis had been diagnosed. He returned to Jamaica, and, as the pain continued, he came to the hospital for the The appendix was, however, purpose of having an operation performed. found to be quite normal, but the right kidney appeared to be firmly bound down just above the brim of the pelvis, but this was not interfered with at the time. He seemed to improve considerably, and talked of returning to his work. On 11th January, about midday, after talking cheerfully about his condition, he suddenly became very blanched and died in a few minutes. A limited autopsy was allowed, in order to discover the cause of his sudden death. A large clot, which must have consisted of some two litres of blood and was the size of half a Rugby football, was found occupying the right flank, pushing down the right kidney and extending behind the liver. There was a laminated clot round the site of the coeliac axis and deep erosion of the twelfth dorsal, first and second lumbar, vertebræ. He had evidently suffered for a long time from aneurism of the abdominal aorta, at the coeliac axis, which had been leaking and finally ruptured. It is a marvel how he could keep on with his work for so long, and also that the aneurism did not burst when he took the anesthetic for the operation for the supposed appendicitis. This diagnosis was based presumably on the situation of the referred pain, along the ilio-hypogastric and ilio-inguinal nerves, and the swelling, or at least resistance, which would be given by the displaced kidney.
(5) E.P., female, aged 56 years. Admitted to hospital on 21st February, 1915, in a semi-conscious condition and unable to give any history. Tem- perature 1010 Fahr. Died the following day. At the autopsy the follow- ing conditions were found: there was excess of fluid in the pericardial The left side of the heart was cavity, but no evidence of pericarditis. normal, but the right side showed extensive valvulitis affecting the tricuspid valve There was a large vegetation hanging down into the right ventricle and almost filling its cavity. The pulmonary artery appeared normal. The lungs showed adhesions on both sides, especially at lower lobe of the left. This was practically solid throughout, though not in a typical condition of red hepatization. There was a small infarct in the lower lobe of the right lung.
The liver was somewhat enlarged and fatty, tough; weight 56 ounces: spleen, weight 7 ounces, fibrotic; kidneys enlarged slightly, combined weight 12 ounces, resembling to some extent the condition of large white kidney. The left The uterus showed submucous fibroids in the fundus portion.
vary was transformed into a cheesy, pulpy mass, but did not appear septic
127
The origin of such extensive endocarditis of the tricuspid valve without involvement of any of the others I cannot say, but the condition is sufficiently rare to merit notice.
hoarse;
(6) C.B., male, aged 31 years. Was admitted to hospital on the 10th March, 1915, in a weak condition and complaining of pain and difficulty in swallowing, of recent onset. He had been under the care of a local prac- titioner for six months for "pain in the abdomen and back." His voice was the pupils were equal. He died on the 12th, two days afterwards. At the autopsy the abdomen was found filled with clot and blood-stained fluid. There was nothing in the abdomen to show whence the blood came. The aorta was dilated from its origin and showed marked atheroma, especi- ally at its descending part of the arch along the thoracic aorta to the level of the thyroid. There was an extensive aneurism of the descending part of the arch, and at the thyroid level was an aperture through which the aneurism opened into the retropharyngeal tissue, and the blood had tracked down between the aorta and the oesophagus, passed through the œsophageal opening of the diaphragm and so into the abdominal cavity, and the clot was mostly over the anterior surface of the stomach and beneath the liver. He had never vomited any blood, for there had been no ulceration into the esophagus itself, but into the connective tissue between it and the aorta, hence the pain and difficulty of swallowing.
8. Two hundred and ninety-two tisanes have been sent up for sectioning. Many of these were from cases of pellagra and of vomiting sickness. Dr. Catto has undertaken this part of the work, and has done it most efficiently. The examination of sections of tissues from the pellagra cases is not yet completed, and until that is done I refrain from giving a description of the morbid anatomy of this affection.
The work on vomiting sickness, which can only be carried out during the winter months, has led to the postponement of the former (pellagra). During the next half-year, if time will allow, a more intimate study of the pellagra question will be taken in hand, and the findings will then be described.
The pathological anatomy of vomiting sickness, though its study has occupied much time, will not be described again, as there is nothing fresh to report, and the detailed description has already been given in previous reports.
9. Under the heading of Miscellaneous may be classed the Wassermann reaction, of which fifty-two have been performed. The method employed is that of McIntosh and Fildes, and was described fully in my September report. The pre- paration of stock and autogenous vaccines comes under the same group, and many of these have been made, and the results reported from their use have been almost uniformly favourable.
The only other subject under this head which may be specifically mentioned is that of diphtheria. Past records of the Department tend to show that this has been almost unknown in Jamaica, but this is, I am inclined to think, due not to its absence, but to its non-recognition. Throat-swabs were sent from one or two sus- picious cases, and were found to be positive; this fact aroused the attention of practitioners to the possibility of the disease being present, and they accordingly sent up swabs from contacts of these cases, and also from other patients exhibiting throat symptoms. Ninety-seven swabs have been sent up, and the bacillus of Klebs-Loeffler has been cultivated from thirty-eight of them.
II. SPECIAL WORK. RESEARCH,
1. Investigations into the question of typhoid bacillus carriers, which were mentioned in my last report,* have been continued. In that report (March- September, 1914) I have appended a table of the results of the bile cultivations from one hundred consecutive autopsies, and showed that " apart from cases treated as enteric fever at the hospital, and apart from cases showing signs of the disease post-mortem, there have been among the first hundred autopsies three who were harbouring the Bacillus typhosus in their gall-bladders," and I stated also that the investigation was being continued and that the results were of sufficient interest and importance to warrant their being more widely known, and I therefore sent a paper on the subject to the "Annals of Tropical Medicine." This has been accepted for publication and will appear shortly.
* See No. 7 in Appendix VIII, in [Cd. 7796], April, 1915.
Page 360Page 361
།། །། ། །
PUBLIC RECORD OFFICE
Reference :-
FC.O. 885
23 PUBLIC RECORD OFFICE, LONDON
ALLY WITHOUT PERMISSION OF THE BE REPRODUCED PHOTOGRAPHIC- COPYRIGHT PHOTOGRAPH-NOT TO
128
I may state here that I have now examined two hundred cases and made the cultivations and tests described in my last report, and the results of my investiga- tions may be grouped in the following way :—
(1.) Number of cases exhibiting signs, post-mortem, of enteric fever from which a positive result was obtained from cultivation of the bile.-Out of the two hundred cases, thirty-six were shown at the autopsy to be suffering from enteric fever; that is to say, definite macroscopic lesions of the disease were present. In thirty of these the Bacillus typhosus was isolated from the bile, and in one other, whose blood during life had given a positive agglutination with B. paratyphosus A and negative with B. typhosus, and who presented symptoms typical of enteric We may, therefore, say that from fever, the Paratyphosus A bacillus was isolated. thirty-six cases of enteric fever the causative organism was isolated from the bile in thirty-one, or 86:11 per cent., although I am aware that the reckoning as a per- This number agrees centage with so few cases as thirty-six is liable to error. practically with the figures of Forster and Kayser (quoted by Hewlett), who obtained pure cultures from the gall-bladders of seven out of eight cases.
A better comparison may be made between these cases and mine if we divide my thirty-six up into series of eight. From the first eight I obtained the B. typhosus in pure culture six times, and twice the organism was associated with a lactose- fermenting one which proved to be the ordinary B. coli. The typhoeus bacillus One of the cases in which the B. coli was thus isolated in all of the first eight. was present also died from a general peritonitis following perforation of a typhoid ulcer, and the bile may have become infected by general systemic infection, or, what is an equally probable explanation, the coli may have entered as a contamina- tion in making the culture. If the former explanation is the correct one, the fact shows that the bile and brilliant green do not always have an inhibiting action on coli organisms.
With regard to the second series of eight, I obtained the typhosus bacillus in pure culture in six, and the B. paratyphosus A in another, also in pure culture; in other words, the organisms were present in pure culture in seven out of eight. In the third series B. typhosus was obtained in pure culture in six, one remained sterile, while from the other only B. coli was obtained. In the next eight the B. typhosus was obtained from all, while in the remaining four B. typhosus was isolated twice in pure culture; of the other two, one gave a growth of B. coli and the other remained sterile.
(2.) Cases which showed no post-mortem evidence of enteric fever, and in which no history of such was obtained, but which, nevertheless, yielded a positive result on cultivation of the bile.-This group is of the greatest importance in lend- ing support to the suspicion on which the investigation was undertaken, namely, that unrecognized possible carriers are going about in Kingston in larger propor- tions than have been estimated in other countries.
As has been already stated, some three per cent. of patients become carriers for a considerable time, but of this series of two hundred autopsies there have been found six who, up to the time of onset of their final illness, had been going about apparently in perfect health, who gave no history of having had an attack of typhoid fever, who mixed freely with their fellows, and lived in the poorer, insanitary, and unsewered parts of the city.
Exclusive, therefore, of cases showing evidence of enteric fever at the autopsy, the bacillus has been isolated from the bile of six subjects:-
1. Dying from arsenic poisoning, suicidal.
pneumonia.
2.
1)
11
multiple abscesses of the liver.
3.
2+
#
4.
+
#1
5.
79
8
chronic nephritis and heart disease. dysentery.
tuberculosis cf lungs, pleura, and peritoneum.
If we deduct the number of those who were suffering from the disease, showing definite signs of it at the autopsy, we may state that out of one hundred and sixty- four subjects there were six who were harbouring the organism of enteric fever.
We are in a position to pass on to consider the deductions which may be drawn from the fact of isolation of the bacillus from the gall-bladder or its contents:- (a) The subjects are chronic typhoid carriers. This is possible, but could not be regarded as proved unless repeated examinations of the excreta vielded positive results. In my cases this was impossible, as they did not come under my observation till after death.
L
129
(b) The subjects are temporary carriers.
i. They may (in the absence of history) have passed through an attack of enteric fever and forgotten or not have known the fact, either because of the mildness of the infection, or because of time elapsing, or because of the illness being wrongly diagnosed. The following cases show that the last may certainly occur: No. 4, diagnosed lobar pneumonia; No. 5, diagnosed pneumonia; No. 9, similarly diagnosed In these three typhoid ulceration was found, but no signs of pneu- monia. No. 10, diagnosed general peritonitis; this was true, but the peritonitis arose from the perforation of an enteric ulcer which had not been suspected. No. 88, diagnosed cerebral hemorrhage; there were the usual signs of enteric fever, but none whatever of cerebral hæmorrhage. No. 99, diagnosed pneumonia; this was present, but there had been no suspicion of enteric fever, which was evident with its typical pathological changes. No. 166, diagnosed colitis, uine days' duration; in this case thirty-two typhoid ulcers were found, post- mortem in various stages; the colon showed no inflamination.
"
ii. They may be "porteurs sains" in the sense of never having had the disease. In this connexion I may quote an interesting case which came to my notice as Government Bacteriologist more than a year ago, and was mentioned in my paper published in the Practitioner for Novem- ber, 1919: "A child of nine months suffered from an attack of typhoid fever proved by isolation of the bacillus. The question then arose as to the method by which the child could have become infected. The little patient's mother was the nurse in charge of the enteric ward at a general hospital in the island, and it was thought that she might possibly have taken some milk or other food from the ward home to the child. A specimen of the mother's blood was asked for, and it was found to give a very marked agglutination of the Bacillus typhosus in high dilution. The nurse was perfectly certain that she had never suffered from typhoid fever, or, in fact, from a prolonged fever of any kind; she had always been healthy, and never remembered being ill in her life' (to quote her own words). The next step was the examina- tion of her stools and urine, and the Bacillus typhosus was isolated from the latter; in short, this nurse was definitely a carrier though never having herself suffered from the disease, and she seems without doubt to have conveyed the disease to her child."
If the subjects are "porteurs sains in the sense mentioned, that is, the organisms are present without setting up the disease, we may find here support for the X Y Z theory of Pettenkofer. Thus it is possible that the bacilli may be harboured in certain situations (in my cases the gall-bladder) for a lengthy period, but until the other components of the etiological complex are superadded no disease results. We may, perhaps, compare it to the lowering of resistance to the bacillus tuberculosis allowing development of the organism and production of the disease.
Against this in my cases is the fact that two (possibly three) of the subjects were considerably debilitated by illness. and there were, nevertheless, no signs of enteric fever supervening. This argument, it must be confessed, is of the nature of a two-edged sword, for, firstly, mere debility by any illness may not be the Y or Z of the ætiological complex, but some element more specific in nature may be necessary; and, secondly, some of the cases which showed signs of enteric fever, post-mortem, although a different diagnosis had been made clinically, might be instances of the supervention of enteric on a previous debilitating disease. This, again, opens up the interesting question as to whether cases of enteric fever arising in patients who have been in hospital for some time, a month perhaps, may not in some instances be of "spontaneous or autogenous" origin instead of being regarded as cases of "contraction of disease in hospital." By the terni spontaneous or autogenous I imply the porteurs sains" who develop the disease after some other debilitating illness, e.g., typhoid