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TC.O. 885

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fever following dysentery, and not merely ordinary cases with a pro- longed incubation period.

iii. The question of lost or diminished motility and diminished agglu- tinability of freshly isolated strains I mentioned in my last report, and have enlarged upon in the paper referred to.

Other points of interest are:-

(a) Length of stay of the organism in the gall-bladder.

As regards the length of time during which the bacillus can exist in the gall-bladder. the limit has not yet been fixed; cases of sixteen, seventeen, and twenty years have been reported by Zinsser, Droba, and Hunner-Writer respectively, and I myself related a case of a fæcal carrier of Bacillus para- typhosus A in 1911 whose primary attack occurred in 1889, twenty-two years previously. Cases reported by Dupré, Ramond, and Faitout are quoted by Bezançon, and it must be remem- bered that all these refer to the duration after an attack of the disease, and the six mentioned in my table-Nos. 7, 34, 73, 113, 137, and 159-gave no history of any previous attack at all, and the time in them is impossible to determine. (b) Presence of the bacillus with and without obvious inflamma-

tory changes in the gall-bladder.

Doerr has stated that the bacilli make a prolonged stay in the gall bladder only if an inflammatory condition of the mucous membrane is set up. In three of my six cases I could not make out any such condition, and it is possible, therefore, that their histories were correct, that they had not suffered from the disease, and that the gall-bladder was merely their tempo. rary sojourning place, a port of call, as it were, in a 'porteur sain," as the bacilli were on their way to being excreted. It may be incidentally noted that gall-stones are very rarely found post- mortem here: of all the autopsies carried out by me during the last four years I have only found them to be present in three instances.

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(c) The question of atypical cases without characteristic changes. Some of those from whom the organism was isolated, although no symptoms were present, and in whom there were no post-mortem signs of the disease, might, of course, be examples of the atypical cases without characteristic changes. Under this head would come such as have been reported as cases of "typhoid septicemia." If by this term we under- stand a systemic affection in which the causative organism not only gains entrance to the blood streams, but also multi- plies therein," I know of no recorded positive findings of such a thing in enteric fever, but an ordinary bacteremia is the normal condition at an early stage of the disease. Absence of evidence of intestinal affection in spite of finding the bacilli in the blood is less uncommon, and may be explained by the fact that all transitions occur between the marked pathological changes in the intestines and a minimal, scarcely recognizable, lesion, and this also apart altogether from the severity of the case. A second explanation is that mentioned in the last section, namely, that the bacilli have gained entrance into the body of a patient suffering from a totally different disease, the subject acting the part of a passive carrier or receiver, as, for example, the entrance into the blood-stream of typhoid bacilli accidentally by way of a tuberculous enteritis.

We must never lose sight of the fact that enteric fever is not an intestinal affection, but a general one with localizations of the bacteria in various situations, most frequently in the intestines it is true, but often in the liver and biliary system, sometimes in the lungs, the bladder, the pleura, the meninges, and so on. Thus, there may be a considerable variety, ranging between a general bacteremia without local infection

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specially marked in the intestines and more definitely localized forms with symptoms of meningitis, broncho-pneumonia, cholecystitis, nephritis, arthritis, etc.; while yet again the typhoid nature of the condition may be masked by accompany- ing infection, such as streptococcal or tuberculous.

2. Lastly, the question of vomiting sickness comes up for discussion. The disease has been very rife this year, and I was sent to investigate an out- break in the Montego Bay district, where it was exceptionally severe, eighteen deaths being reported in two days. I visited, in company with Dr. G. W. Thomson, the District Medical Officer, the parts of his districts where cases had occurred and were still occurring; I saw several patients, performed autopsies on those who died while I was in the locality, and obtained detailed histories of thirty-five cases

in all.

Three of these were not cases of what is ordinarily known as true vomiting sickness, though a superficial view of the symptoms might confuse them with that disease. These three may be summarily disposed of. The first was a case of acute hæmorrhagic pancreatitis (it may be incidentally mentioned that the poison causing vomiting sickness appears at times to set up hemorrhages in various organs and the pancreas is not exempt, and thus acute hæmorrhagic pancreatitis in children may be one of the manifestations of the disease out here); the second was probably one of ordinary infantile convulsions without the usual concomitant symptoms of vomit- ing sickness; both of these terminated fatally. The third was a patient suffering from ordinary malaria of fairly long standing, not an acute case at all. I found the parasite (Pl. falciparum) in her blood, and she made a complete recovery on the usual antimalarial lines of treatment.

may, therefore, say that I made inquiries into thirty-two cases of what we now describe as vomiting sickness. These will be briefly related, and the general points which arise from a consideration of them will be then dealt with:-

(1) S.M., female, 12 years of age. On 16th February, 1915, went to school perfectly well. About 4 p.m. complained of pains in the stomach and vomited three times. Then felt better and tried to get home, but on the way again felt ill and vomited, and so stopped to rest at a house. At 6 p.m. her mother came to take her home, a distance of three miles. On arrival there (7.30 to 8 p.m.) she passed into a state of coma, but had no convulsions, and died about midnight. At the autopsy the following conditions were found: body well nourished, meningeal vessels very con- gested, stomach congested, petechiæ near cardia, liver fatty, spleen nor- mal, kidneys slightly congested, pancreas normal, mesenteric glands swollen and hyperemic, ascarides numerous.

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The nature of the previous meal not known; many ackee trees with ripe fruit in the yard.

(2) D.G.. female, 6 years. Quite well on going to bed on the evening of 16th February. The following day at 5 a.m. she vomited twice, but did not complain of any pain. She felt sick all that day and stayed in the house; slept fairly well during the night of the 17th. At 6 a.m., 18th. she vomited again and immediately afterwards had a convulsion and passed into a state of coma, in which she died at 2 p.m. She never made any complaint of pain.

At the autopsy the usual conditions were found and need not be repeated.

Her food consisted of yams, bananas, and “probably ackee" (mother's words). There were many in the yard, but the mother would not say for certain whether the child had eaten them.

(3) N.R.D., male, aged 10 years.

At 5 p.m., 17th February, complained of pain in his stomach and began to vomit: continued to do so till 1 a.m., 18th, when convulsions set in followed by coma, which lasted till death

at noon.

The autopsy revealed the usual signs; but there were also ascarides present

The food in this case consisted of yam, salt-fish. ackee, and bananas boiled together, and eaten at 3 p.m. on the 17th. The ackee was mostly removed and eaten by the older members of the family (see Nos. 5, 6, and 7), leaving the "soup 11 or "pot-water" for this child and the one whose history is next recorded.