15

Mesopotamia which appears to be identical with the THE PARATYPHOID "C" BACILLUS AS A B. paratyplwsus C of Hirschfeld. Macadam isolated this. FEVER. bacillus from 7 cases by blood culture, and on 2 occasions post CAUSE OF PARATYPHOID mortem (1 from lung and 1 from bile). Mackie and Bowen 4 isolated the C bacillus from BY LEONARD S. DUDGEON, C.M.G., C.B.E., para. 12 cases, 10 from the blood stream, 1 from the urine, and F.R.C.P. LOND., 1 from the liver. The authors state that the paratyphoid C PROFESSOR OF PATHOLOGY, UNIVERSITY OF LONDON; bacillus does agglutinate with some samples of antipara- AND typhoid B serum to low titre, and also that the para. B co- A. L. URQUHART, O.B.E., M.B. EDIN., D.P.H. LOND., agglutinins are removed from the para. C antiserum by the para. C bacillus. Macadam noted on several occasions zones ST. THOMAS’S SENIOR ASSISTANT BACTERIOLOGIST, HOSPITAL. of inhibition of agglutination with the para. C reaction. (From the Pathological Department of St. Thomas’s Neukirch 6 while working with the German Army refers to his Hospital and the British Laboratories attached findings in Turkey. He cultivated from the blood, urine, to the Balkan Forces.) and faeces, bacilli allied to the paratyphoid B. bacillus, but serologically distinct. Although he does not give the name C to these it is from his results that in ’ para. organisms, probable (Bacteriological Investigations Macedonia, 1916-17-18.) some of his strains were identical with the bacillus of IN 1916 Professor Ludwig Hirschfeld, bacteriologist- Hirschfeld. On clinical evidence some of the cases were in-chief to the Royal Serbian Army, isolated by blood typical enterica, others were dysenteric in character. Dienes 7 also similar culture a bacillus which, for reasons about to be defined, and Wagner obtained findings to those recorded by Neukirch. he labelled C." The patients from whom ’ s "Paratyphoid Garrow has published a case recently of a paratyphoid C the organism was cultivated were suffering from The 6, which occurred in East Africa. patient pre- but no known bacillus of the enterica enterica," group sented the clinical features of a typical enterica infection. was isolated and no serological confirmation was The paratyphoid C bacillus was recovered from the blood obtained. Professor Hirschfeld considered that the stream and the patient’s serum contained specific agglutinins organism was distinct from the known paratyphoid for this organism. No paratyphoid B agglutinins were bacilli isolated from the Serbian soldiers suffering from present. enterica, and he decided to add this bacillus to his Patal Cases. preventive vaccine. In December, 1916, a vaccine We were able to obtain details of two cases of fatal was prepared in his laboratory at Sedes which con- para. C infection in the Balkans, although other cases tained B. tphos2cs and paratyphoid bacilli A, B, and C, no doubt occurred. and V. cholerce. This vaccine ivas employed in the CASE 1.-Macedonian labourer. Investigated by Captain J. Serbian army for preventive inoculation in 1916, 1917, Anderson, R.A.M.C. B. Daratilphosus C was isolated hy blood culture from this who was ill with and 1918. In a bacillus was obtained patient profoundly "enterica,," December, 1916, and subsequently died. At the autopsy the spleen was found to be by blood culture from a Serbian soldier at an Anglo- much enlarged, very soft, and congested. There was no intestinal Serbian hospital suffering from enterica, and as it was ulceration, but marked patchy congestion of the intestinal wall. found to be atypical it was sent to one of us (L. S. D.) CASE 2.-A Macedonian woman was admitted to hospital at for further This to be Vodena, and died on the eighteenth day after a severe illness. investigation. organism proved This patient was diagnosed clinically as enterica. No malarial a strain of the para. C bacillus. An antiserum which parasites were found in the blood film, and the cerebro-spinal fluid was prepared with this strain of para. C corresponded was normal in all respects. An agglutination reaction on the thirteenth day of the disease gave a 5880 reaction to para. C, while two to the C antiserum to us Professor para. supplied by days later it reached ld’õ5õ, but no reaction occurred with the Hirschfeld, and the organisms were in all respects typhoid, para. A, or para. B antigens. No further observations were similar. possible, as the patient was many miles away from a British unit. it was decided to prepare a para. u antigen for the agglutination Reactions Obtained in Iacedo2ia. laboratories in Macedonia similar to those employed for the typhoid and paratyphoid A and B reactions at Captain Anderson, bacteriologist to an Anglo-Serbian made the observations :— the Central Laboratory, and also a supply of para. C Hospital, following He examined the blood of 104 for evidence of antiserum. At this was patients typhoid subsequent periods organism and paratyphoid A, B, and C agglutinins with the antigens supplied isolated by blood culture from Serbian soldiers (6) in by us. Of these patients, 11 were British, 9 French, 58 Serbians, and further and the remainder included the " mixed bag " of people met with Anglo-Serbian hospitals, strains werei obtained from the faeces of Serbs and others whoi in the Balkans. (10) Only 2 out of a total of 58 Serbians gave a reaction to the were suffering from severe diarrhoea or enterica. The para. C antigen. In the first case the Serb had been inoculated organism was not isolated by us or our co-workers against the enterica group one month previously with Hirschfeld’s mixed vaccine and gave a reaction of B§§B for para. C, for from the urinary tract. It is now known that, in ls oo typhoid, and for para. A, but no para. B reaction. In the addition to typical enterica, the B. paratyphosacs C may 1 00o second case the Serbian soldier had been inoculated against the rise to infective such as severe give conditions, enterica group one year previously, and showed a 5000 reaction to diarrhoea, broncho-, and general sepsis. para. C, a slightly greater typhoid and paratyphoid B reaction, but Castellani,1 in an article on typhoid in the none to para. A. Further, although 8 cases gave a reaction of Adriatic-Balkan Area," refers to a number of "atypical 1 in 100 or over with our typhoid antigen, and one case to "’08000 with or mixed enterica infections." He states that six strains the para. B, there was no reaction at the lowest limit with the C were isolated with the cultural characteristics of the para. antigen.9 B. paratyphoszes B, but serologically distinct, and three To elucidate further the question of degree of response strains culturally similar to the paratyphosus A, although to the para. C portion of the quadruple vaccine this distinct serologically. organism was embodied in the vaccine to be employed Archibald, Hadfield, Logan, and Campbell,2 in their for the inoculation of 20 volunteers amongst the Bulgar report on the diseases affecting the troops in the Darda- while the remainder received- the state that out of 147 cases of 21 were due to prisoners, triple nelles, enterica, blood man B. 41 to B. and 70 to B. vaccine. The of each was tested for his typhosus, paratyphosus B, para- to and and tzlp7wsus Á, while 15 inagglutinable para. A strains and agglutination response typhoid, para. A, B, 14 para. B were also obtained. C before inoculation, and again ten days later. The Kennedy,3 in an article in the Journal of the R.Á.]}1.C., local and general effects of the quadruple vaccine were reports that in 1914 at the Enteric Convalescent Depot at considerable in many cases, while in all a definite local Naini Tal he found five inagglutinable strains by blood reaction occurred. In five cases pyrexia exceeded culture, resembling B. paratyphosus A or B. 100° F. on the second day after the inoculation, but in Macadam,5 Mackie and Bowen 4 isolated a bacillus in two of these men it was probably malarial in origin. 1 Castellani: Typhoid and Allied Infections in the Adriatic- Balkan Area, Ann. Med. Nav. and Colon., 1916, November- 5 Macadam, W.: An Account of an Infection in Mesopotamia due to a of the R.A.M.C. December, vol. ii., pp. 453-461. Bacillus Gaertner Paratyphoid Group, Journal, 2 R. G., Hadfield, G., Logan, and W.: August, 1919. Archibald, W., Campbell, Menschliche Reports on the M. and H. Laboratories, dealing with the diseases 6 Neukirch, Paul: Uber Erkanshungen derch Bazillen affecting the troops in the Dardanelles, R.A.M.C. Journal, June, der Glasser-Voldagsengruppe in der Turkie, Zeitsch. für Hygiene 1916, vol. xxvi., pp. 695-724. und Infektions, 1918. 3 Kennedy, J. A., Lieutenant-Colonel, R.A.M.C.: Inagglutinable 7 Dienes, L., und Wagner, Richard : Über Paratyphus B-infek- Paratyphoid Bacilli (Paratyphoid C) in India, R.A.M.C. Journal, tionen, Zeitsch. für Hygiene und Infektionskr., 1918. August, 1918, vol. xxxiii., p. 190. 8 Garrow, R. P.: A Case of Paratyphoid " C " Fever in East Africa. 4 Mackie, F. P., Major, R.A.M.C., and Bowen, G. T., Captain, THE LANCET, June 5th, 1920. R.A.M.C.: Note on the Characters of an Anomalous Member of the 9 It is a matter of considerable difficulty to obtain reliable Paratyphoid Group met with in Mesopotamia, R.A.M.C. Journal, information concerning preventive inoculation among the Serbian August, 1919. soldiers. 16

In every instance enlargement and tenderness of the TABLE III.-To Show the Aggtlutinin Content of Iq?bini4ne axillary glands occurred. Rabbit Sera Titrated with our Standard Antigens as Aggl1dination Response. Used in the Above Experiments. It will be seen from Table I. that of the 20 Bulgars whose blood was tested before inoculation 10 gave a rn-uu reaction to the typhoid antigen, and 1 a 14H-6, while only 3 reacted to the para. A antigen, one of them to the extent of J:%-&8o. No reaction occurred with the para. B antigen, and in only one instance with the paratyphoid C. The agglutination response, therefore, to the antigens was feeble or entirely paratyphoid - absent. No evidence was obtainable as to whether n n i i these men had been inoculated previously with a triple Cultural Tests. had received a vaccine vaccine, although they typhoid Every strain of para. C tested by us has shown the same some months previously. cultural reactions, and, further, these reactions have The inoculation of our quadruple vaccine excited an remained constant in stored laboratory cultures. active response to the T. A and B antigens, but a The organism is a motile Gram-negative bacillus. It ferments and sorbite C reaction occurred in only one instance (Case glucose, mannite, maltose, dulcitol, 2); with while cane and lactose remain here a reaction of was obtained before gas production, sugar 1>&bgr;-B-õ inoculation, unchanged. Litmus milk is first acidified, the medium which rose ;to ten days after the injection of the gradually returns to neutral point, and finally is rendered vaccine. In two instances a B reaction of was alkaline in three to four days. No strain which we have produced, but no C reaction was obtained. investigated has produced indol. The same strain of para. C bacillus was employed for Since the above observations were made in Macedonia the preparation of the vaccine and antigen. we have further investigated the serological reactions TABLE I.-Agglutination Response to One Dose of of the para. C bacillus and compared its antigenic Quadruple Vaccine in Bulgarian Soldiers. properties with the other members of the enterica group of organisms. Rabbit antisera have been prepared and the reactions to the enterica group, including the para. C bacillus, have been studied. Three types of vaccines were employed : (1) heat-killed, (2) formol- killed, and (3) vaccines grown in 1 per cent. dextrose 10 and killed with formalin. Para. C. vaccines have also been employed for the inoculation of men who offered their services, and the antigenic properties were observed in these healthy individuals, many of whom were ex- soldiers and whose sera contained typhoid and para- typhoid (A and B) agglutinins. Methods of Preparation of Vaccines. The vaccines employed by us in these investigations were made as follows :- 1. Heat-killed vaccines.-A 24-hour agar culture of this organism was emulsified in normal saline, filtered through fine linen, and heated to 560 C. for one hour. The vaccine was then placed in the ice chest, and later tested for sterility. Suitable dilutions of the emulsion were made with saline containing 0’25 per cent. carbolic acid. 2. Formalin-killed vaccines.-A 24-hour agar culture was emulsified in normal saline and filtered as above. To the End-point of C, 5000. antigens, typhoid, 15,000; A, 10,000; B, 8000; emulsion 0’1 to 0’14 per cent. of formalin was added and the Note: 0 = 1/25, no reaction. emulsion placed in the ice safe till sterile. Suitable dilutions These agglutination reactions with the Bulgar were made as above. prisoners agreed with our findings obtained with the 3. Acid dextrose vaccines.-Organisms were grown in 1 per Serbian soldiers, and may serve as an explanation for cent. dextrose in peptone water and the tubes were incubated the absence of a reaction in the latter, although we had for 24 hours. The acidified medium was centrifugalised and believed them to be inoculated with.Hirschfeld’s mixed the supernatant fluid discarded. The deposit of organisms was diluted with saline 0’1 to 0’14 cent. of vaccine. It must be that it was containing per remembered, however, formalin and treated as in method 1. to test the reactions the subsequently possible agglutination among Some of the volunteers received one type of vaccine only, on one occasion after the of the Bulgars only injection and others one type followed by another. Rabbits were vaccine, as they were required for military purposes. also inoculated with the vaccines and the agglutinin response Further, the highest agglutination reaction observed tested. among the cases of para. C infection by us was The antigens used were made as follows :— Animal Inoculations. The organism was subcultured daily for 10 days to obtain an flasks were inoculated with the A rabbit was inoculated with 50 million of active growth. Agar subcutaneously tenth and the flasks were incubated for 24 hours. ’each organism in a quadruple vaccine, nine later with subculture, days The was washed off with 0’1 to 0’14 cent. formol 100 million, and again eight later the dose was growth per days repeated. saline. The emulsion was filtered and in the ice The agglutinin response is tabulated in Table II. placed chest till sterile. The antigen was diluted to standard, i.e., TABLE II.-Rabbit Inoculated Subcutaneously with 1000 million bacilli per c.cm., and 0’25 per cent. carbolic acid T. A B C Vaccine. added. The end-point of agglutination is expressed as a T. A B C fraction, the numerator denoting the highest dilution in 0 0 0 0 ... Before inoculation. which agglutination occurred, the denominator being the of the on its antiserum. Our 50 Malian T. A B C Subcutaneously. end-point antigen homologous methods for the agglutination reactions were constant, and ... 9 days after first inoculation. we followed in certain details the technique recommended 100 Million T. A B C Subcutaneously, by Dreyer. The tubes were incubated at 550 C. for two 8 days after second inoculation. hours, and the readings taken after half an hour at room 9 days after third inoculation. temperature. A second rabbit was inoculated subcutaneously with The absorption tests were carried out as follows :- 10 million of each organism employed in the quadruple To one volume of the serum diluted to 1 in 10 with normal and seven later with 20 but a similar vaccine, days million, saline a creamy, thick emulsion of the absorbing bacillus 11 was obtained as shown in Table II. agglutination response was added in three doses, i.e., one half and two quarter The two rabbit experiments just referred to show that these animals give a response to each member of the 10 This vaccine will be called subsequently in this paper the quadruple vaccine when the immunisation has been obtained " acid dextrose vaccine." with or doses. large average 11 These emulsions were approximately of the same strength. 17

volumes, at intervals of three hours, and incubated at 550 C., of suipestifer and para. C. The results obtained by him unless otherwise stated. After nine hours the tubes were would appear to us to be of the utmost importance placed on the ice overnight. The treated emulsions were epidemiologically. and the test on the centrifugalised performed supernatant TABLE and Reaction Five clear fluid. A control saline and serum tube was heated VI.—Agglutinin Absorption of together with the emulsions. Bacteria on Para. C Artiserum. Agglutinin Response of Rabbits to Injections of the Para. C Bacillus. A rabbit was inoculated intravenously with a formol agar vaccine of the para. C bacillus, and the response is recorded with the dosage in Table IV. TABLE IV.-Intravenous Inoculation of a Rabbit with Formol Agar Vaccine of the Para. C Bacillzas.

The end-point of the reaction was not determined. The Effects of the Injection of Multiple Vaccines Contain- ing B. typhosus and B. paratyphosus A, B, and C into Rabbits. Rabbits were with the vaccine sub- This rabbit gave a rapid serum response that is, to injected quadruple the of the cutaneously and intravenously, as noted below. Three types end-point antigen. of vaccines were This C antiserum was tested the stock employed: (1) heat-killed, (2) formol-killed, para. against and acid laboratory antigens, B. typhosus and B. paratyphosus A, B, (3) dextrose. and C, with the following results: A control tube containing TABLE VII.—To Show Results of Injecting Subcutaneously normal human serum and the para. C antigen was also equally graduated Doses of Heat-killed Vaccines of observed. B. typhosus and B. paratyphosus A, B, and C. Typhoid antigen and para. C antiserum ... 0

Para. A ... " " " " 20000.

Para. B " " Para.Para C 20000 " " " " 200002000U Para. C normal serum " " " " 20000 From these results it will be seen that the para. C agglu- tinin is specific, as no reaction occurred with the typhoid or paratyphoid (A or B) antigens. TABLE V.-Absorption Test. Para. C Antiserum Saturated with B. typhosus and Paratyphoid Bacrlli A, B, and C.

From Table VII. it will be seen that the agglutinin response was present to each component of the quadruple vaccine when the heat-killed vaccine was employed. A similar experiment was carried out with the formol- killed vaccine, and in this instance, as in the case with the heat-killed vaccine noted above, a similar rise of agglutinins was noted. The quadruple vaccine was given in doses of 100, 200, 400, and 500 million at six-day intervals, and the agglutinin titre of the serum rose from zero to with B. with with and * In all cases 1 in 15,000 dilution gave complete agglutination; the typhosus, para. A, para. B, end-point was not obtained. with para. C antigens. It will be seen from Table V. that no absorption of the TABLE VIII.-To Shozv the Results of the Subcutaneous " C " agglutinins followed the addition of the typhoid and the Inoculation of Rabbits with the Quadruple Acid A and B bacillary emulsions. The effect of absorbing the Dextrose Vaccine. stock para. B antiserum with emulsions of para. B and C showed that a B antiserum of titre was completely desaturated by a para. B bacillus, while the para. C emulsion removed none of the para. B agglutinins. It will be seen from the above-mentioned experiments that the other members of the enterica group absorbed none of the agglutinins from a para. C antiserum of high titre, and that the para. C bacillus absorbed none of the agglutinins from this sample of para. B antiserum. It is necessary, however, to realise that some para. C antigens have a definite B fraction, while apparently a B fraction may develop in a C antigen which was pure when the organism was first isolated. - We conclude that the B and C A second rabbit was inoculated in this case intravenously para. para. bacilli, although with the acid dextrose and the identical in fermentation are distinct bacteria as quadruple vaccine, agglutinin reactions, is recorded in Table IX. judged by serological reactions, as Professor Hirschfeld response originally stated. TABLE IX.-To Show the Immediate and Active The reactions and tests with a C Response agglutinin absorption para. Obtained with Acid Dextrose Vaccine when antiserum were tested against two strains of Gaertner bacilli Quadruple and Aertrycke bacilli kindly supplied to us by Colonel Injected Intravenously. S. L. Cummins, A.M.S., with the results shown in Table VI. It will be seen from this table that the paratyphoid C strain has apparently no relationship with the Gaertner or Aertrycke group of bacteria, as in no case was anyagglutina- absorption phenomenon observed.* - tionSir or Frederick Andrewes, to whom we are greatly indebted for showing us the results of all his investigations, has found that typical strains of suipestifer and para. C are identical serologically. We have tested the original strain of para. C isolated by Hirschfeld in 1916 with a standard strain of suipestifer furnished by Andrewes. On serological evidence The difference in response is very marked, as shown in the two strains are identical. Cultural differences with xylose, arabinose, and dulcite may occur with some strains thesesubcutaneously two tables. Inexcited 19 daysbut thea acidfeeble dextrose response vaccine to all given four 18 antigens, whereas the same vaccine given intravenously obtained, while in eight instances the men received two or excited in 11 days a marked reaction with the paratyphoid more doses varying from 250 to 1000 million, but only a very strains, but not with the typhoid. feeble agglutination reaction occurred. It was thought that this feeble response to the acid dextrose It would appear, therefore, that the acid dextrose vaccines, vaccine employed subcutaneously might be due to the absence when given subcutaneously in man, fail to excite any of reaction in the tissues at the site of inoculation. Two marked agglutinin response, and these findings are similar further rabbits were inoculated subcutaneously-(a) with to those made in rabbits when this form of vaccine was acid dextrose vaccine only, while (b) received 0’5 c.cm. of used subcutaneously. ether at the site of inoculation to ensure a tissue response. The Action Heat on Human and Rabbit C In Rabbit (a) the agglutinin reactions were again feeble, of Paratyphoid similar to the previous experiment referred to in Table VIII., Agglutinins. while in the case of Rabbit (b) no advantage was obtained by Seven human para. C antisera were obtained by the sub- exciting a marked local reaction by means of ether. Rabbit (a) cutaneous injection of paratyphoid C vaccine. Four of these subsequently received two injections of the quadruple formol- antisera diluted to 1 in 10 with normal saline gave titres of killed vaccine subcutaneously and Rabbit (b) one injection 1 in 800,1 1 in 1000, 1 in 1100, and 1 in 1500 respectively. These of acid dextrose vaccine intravenously, and in both cases a sera were heated for nine hours at 550 C., and when re-tested marked reaction to all four antigens occurred. it was found that the end-points had fallen to 1 in 200, 1 1 in and 1 in 400 The three remain- From these experiments it may be concluded that as in 200, 25, respectively. C when were heated at 55° C. for an for the of ing para. antisera, diluted, antigen preparation typhoid and para- six hours. The of before and antisera the heat- end-points agglutination heating typhoid (A, B, C) agglutinating were 1 in 150, 1 in 300, and 1 in 2000; after heating the end- killed and formol-killed vaccines are of greater utility points had fallen to 1 in 50, 1 in 200, and 1 in 800 respectively. than the acid dextrose if the subcutaneous method of It will be observed that in all cases the paratyphoid C agglu- inoculation is employed, but the acid dextrose vaccine tinins were reduced by heat at 550 C. In one experiment in gives an equally good result if paratyphoid vaccines are which a sample of human antiserum was heated at 37° C. injected intravenously.12 for nine hours a considerable loss of agglutinin content occurred. Two rabbit antisera were heated along with the The Result of the Subcutanceous Inoculation of Man with human antisera at 55° C. for nine hours, but in one case a Paratyphoid C Vaccines. slight fall from 1 in 25,000 to 1 in 20,000 occurred, while in the other a fall from 1 in 1500 to 1 in 1250 resulted. Over 30 volunteers have been inoculated subcu- Thus the human paratyphoid C agglutinins appear to be taneously with paratyphoid C vaccines. The. highest partly thermolabile, while the rabbit para. C agglutinin is agglutinin responses were obtained with the formol- but slightly affected by heat. killed vaccines. inoculation in The dosage varied C Human and the serum reactions Absorption of Paratyphosus Agglutinins from amount, resulting appeared Sera: Zonular Agglutination. to have no with the number of bacilli relationship The sera of four men who had been inoculated subcu- Thus, after a dose of 250 million injected. single taneously with paratyphosus C vaccine, and in whom a good of the a titre of was formol-killed vaccine, response was excited, were absorbed with emulsion of B. obtained; in another instance, although 11 inocu- paratyphosus C. Before the absorption test was carried out, lations were given over a period of four months, the titres of the sera were 1 in 800, 1 in 1000, 1 in 1100, and seven of which contained 1000 million bacilli, the 1 in 1500 respectively. In all four cases complete removal of the C as para. C agglutinins never rose above while in paratyphoid agglutinins resulted, but, already the of the C in man other cases no reaction occurred. Two healthy men stated, thermolability para. agglutinins must be allowed for, as we found that in the serum received two each of 250 and 500 million of a fully injections saline control tubes the titres of the sera had fallen very para. C vaccine at an interval of eight days. In one considerably. instance the titre of the serum to para. C rose from The absorption tests were carried out with two of these 0 to 1500 in four weeks, while in the other instance no antisera at 37° C., instead of 55° C., but it was found that the response was effected in the same period. It would agglutinins were completely removed, as occurred at the appear, therefore, that the agglutinin response to para- higher temperature. C in individual is uncertain Zonular agglutination was noted in 3 of the 35 men typhosus any particular inoculated with the C vaccines in but was not and be absent. These para. London, may altogether findings agree observed in any of our rabbit antisera. The three human with our observations made on the Serbian soldiers, sera above referred to gave agglutination readings as and on the Bulgarian prisoners in Macedonia. follows :- to the Inoculation Ia’ormol- (1) 1/25 = 0, 1/50 incomplete, 1/100 to 1/1000 complete, 1/2000 end- Agglutinattion Response of point of agglutination. killed Paratyphoid C Vaccines. (2) 1/25 a trace, 1/50 to 1/100 complete, and 1/1000 end-point of Twelve men were inoculated with the formol-killed agglutination. = a and and in all but in whom no was (3) 1/10 0, 1/25 trace, 1/50 1/100 complete, 1/1000 end-point of vaccine, two, response agglutination. a marked reaction occurred. Local excited, agglutination This which rise to fallacies when reactions were noted in a few of these cases. Four cases phenomenon, may give human antisera are under has received a of C and the titres investigation, also been single injection para. vaccine, referred to Macadam 6 while in of the sera between the fourteenth and the twenty-first day by working Mesopotamia. day were 1 in 500,1 in 800,1 in 1000, and 1 in 1500 respectively, The Formation of Paratyphoid B Coagglutinins in the with an antigen of 1 in 20,000 end-point. Three men Sera Persons Inoculated with B. C. received two doses of vaccine at intervals of six to of paratyphosus eight days, of the men who acted as volunteers for these and after 15 the to C was 1 in 1 in Many days response para. 200, had served in the and had been inoculated and 1 in 1500 Of the three cases investigations army 300, respectively. remaining with the enterica vaccine. The sera of these men one received doses of 500 and 750 and two 500 and triple million, were tested for the of and 1000 million, at an interval of seven and the titres of presence typhoid paratyphoid days, As a result of these observations the men were the sera for C agglutinins were 1 in 300, 1 in 100, and 1 in agglutinins. 1100 divided into two groups : (1) those who gave no reaction, and respectively. a B From the above in which formol-killed (2) those in whom para. response was present with a, experiments, para- B of 1-5000 C vaccines ware a definite para. antigen end-point. typhoid used, agglutinin response was inoculated with a but the of the vaccine did not to Each group formol-killed para- occurred, dosage correspond C vaccine with doses from 250 to 1000 million, the agglutinin reaction in any way, as one man after three typhoid varying and as a result it was found that some men of both groups doses failed to respond, while a second, who received a single showed a definite rise in the titre of the para. B inoculation of 250 million, gave a reaction of 1 in 1500. agglutinins, while others failed to respond. This para. B agglutinin The Inoculation of Men with the Acid Dextrose Vaccine. response was not dependent upon the amount of paratyphoid C The result of subcutaneous inoculation of the acid dextrose vaccine injected. vaccine was observed in 11 cases. In no instance was Para. C Infection in London. one in any local reaction observed, and with exception, In March, 1920, the B. paratyphosus C was grown in blood which a slight para. C reaction was obtained previous to culture from a case of enterica admitted to St. Thomas’s the excited were feeble. In the case inoculation, responses Hospital. On March 18th a girl (M. N.), aged 12 years, was million were referred to, doses of 250 and 500 given, and at admitted under the care of Dr. C. R. Box, who has kindly the end of three weeks a reaction of 1 in 1500 was obtained. permitted us to publish the following notes. In two cases in which 250 and 500 million bacilli were The patient had been ill for two days, suffering from headache, with a no was injected 5-day interval, agglutinin response vomiting, and general malaise. She had a rigor immediately pre- ceding admission. On admission the temperature was 102° F. and 12 It must be noted that the para. C antigens prepared by us in the pulse 112. No spots were seen. The spleen was enlarged and London were considerably more sensitive than the typhoid and palpable. On March 21st the temperature reached 1040, and the paratyphoid A and B, and that the results of the C agglutinin patient was delirious. Pulse 132. Epistaxis occurred. The tempera- response must be considered with due regard to this factor. ture lasted for six days after admission, and then fell to subnormal 19

and remained so throughout convalescence. Bowels were con- been present within two years of the primary lesion, A blood culture was made on March stipated throughout. 22nd, and one case is on record where the and the serum was also collected. The blood culture in distilled ruptured water grew a Gram-negative motile bacillus, which gave the three months after the primary sore appeared. cultural reactions after seven days’ incubation of the B and C In the of the cases the is of a much more bacillus. majority chronic nature, and has been latent for a number of a The serum was tested on March 22nd and 29th and April 9th. On years, the first occasion against B. typhosus and B. Paratyphos us A and B sudden exacerbation of the lesion drawing attention to its no agglutination occurred. The para. C reaction was also tested nature. The majority of cases in the U.V.F. Hospital come on the second and third occasions, but no reaction was obtained. into this chronic type. has almost always been This bacillus was not agglutinated by the patient’s serum, and denied at first, probably due to the fear of loss of pension, when tested with the stock typhoid and paratyphoid A, and C and partly to the fact that the men thought they were com- antisera the results: T = A = B, and gave following 0, 0, B cured because no have been seen for = many C The faeces were examined on four occasions, but the pletely signs para. C bacillus was not recovered. No history was obtained of any years. relative having been in the East. The father, a soldier, had been McCrae and Adami 2 divide into two types-the in France, but had never suffered from any enterica-like infection. elastic and the muscular. The aorta and its main branches Sir Frederick Andrewes has very kindly informed us of a are of the former type, and this elasticity is of the greatest case of para. C infection which occurred at St. Bartholomew’s importance. The aorta receives the first impulse of the Hospital in 1919, in a man who had been in Mesopotamia. blood wave, and is subject to sudden expansion. The elastic The organism was obtained by blood culture and from the fibres, alternating in the media with the muscle fibres, are urine. The case, however, was not enterica on clinical needed both to prevent undue distension and to bring the evidence. vessel back to normal. The change in this middle coat is In conclusion, we offer our thanks to Professor Hirschfeld, the important one in syphilis, as it interferes with the who supplied us with the original strain of the B. para- contractile and expansile power of the aorta. typhostcs C in 1916, and to our various colleagues in the The ascending and transverse portion of the aorta are Balkans who assisted us with our observations, more specially susceptible. Some attribute this to the infection especially to Captains W. J. Deadman and J. Anderson, being carried by the vasa-vasorum, a theory which also R.A.M.C. accounts for the frequent involvement of the cerebral arteries. ______Another theory is that the spread is a lymphatic one, and the first part of the aorta, containing a large number of SYPHILITIC AORTITIS. lymphatics, is most frequently affected. These lymphatics follow the vasa-vasorum, and account for the perivascular BY S. B. BOYD CAMPBELL, M.C., M.B., infiltration. The change is principally in the media, and is of a chronic inflammatory nature. The tunica adventitia is F.R.C.P. EDIN., also involved, producing a connective tissue overgrowth. PHYSICIAN TO OUT-PATIENTS, U.V.F. HOSPITAL ; MEDICAL TUTOR, Intimal changes are secondary and also show a connective ROYAL VICTORIA HOSPITAL, BELFAST ; LATE MAJOR, R.A.M.C. tissue . If the weakening of the media is slow, the secondary thickening of the intima counteracts the strain, WHILE working at the Ulster Volunteer Force Hos- and the dilatation, if present, is slight; if change in the pital with Dr. J. E. MacIlwaine I was greatly struck by media is rapid the wall may give way, with formation of an the fact that the Wassermann reaction had been positive . Dilatation may be either local or generalised, and in all the cases which showed evidence of an aortic depends partly on the strength of the aortic wall and partly and I therefore have sent aortic case met on the internal pressure. lesion, every arterio-sclerosis differs from the with at boards to have a Wassermann test Non-syphilitic syphilitic pensions both in distribution and in the coat affected. In the done. The result showed how it is to have the type important former the patches are usually seen at the orifices of the blood examined in these cases. Of 25 cases met with in aortic branches, especially the intercostals, and the change the hospital and at the boards only one gave a negative is primarily an intimal one, often with calcareous deposits. Wassermann. In this case there was a definite history In the latter the patches are usually transverse, bear no of rheumatism in a young man and the aortic lesion relationship to emergent vessels, have a puckered appear- was a thus from the ance, and are usually secondary to a mesaortitis. , differing syphilitic type, The aortitis from acute which is never a true stenosis. arising rheumatism, streptococcal infections, and so forth, tends to subside as the primary The Ætiology of Aortitis. lesion improves. In syphilis the lesion is progressive unless treatment is carried and even infection may cause aortitis, but the two most vigorous antisyphilitic out, Any then it is very refractory to treatment. The aorta is one of common are rheumatic fever and syphilis. the most frequent sites of latent syphilis ; Warthin demon- in The relative age-incidence these two diseases is strated active lesions of the aorta in every case of latent important. In patients below 40 a fair proportion give syphilis examined. a history of acute rheumatism. The recruiting for the war The lesion usually leads to a dilatation of the aorta, either a had a showed that considerable number of aortic lesions general or localised. The is often in recent work the rheumatic history, while pensions great attributed to a relative ilicompetencelfollowing the aortic majority of cases point to a specific infection. There is often dilatation, but the finding, by the Levaditi method, of great difficulty in making a definite diagnosis as to cause, spirochætes in the aortic tissues shows that the insufficiency especially where syphilis is denied and a Wassermann test is is an organic one, and, as is usual in syphilis, the change is negative. The post-mortem room is a great teacher, and one of dilatation due to sclerosis of the valves. to 1 According often upsets a clinical diagnosis, as recent work by Warthin Mix 3 syphilis never causes an aortic stenosis. has proved. He has shown that spirochsetes are present in The specific change may involve the heart muscle, leading the aorta, aortic valves, and even in the myocardium in a to all the symptoms of a myocarditis. Two of the cases that great many cases in which a clinical diagnosis of syphilis died in the U.V.F. Hospital showed well-marked signs and had not been made. symptoms of myocarditis. There was a post mortem on one The history of rheumatic fever does not exclude the case, and the heart showed myocarditis. Spirochætes were possibility of a coexisting syphilitic lesion. For instance, not looked for, so the specific origin was not proved. one of Dr. MacIlwaine’s cases in the U.V.F: a Hospital gives ’ historv as follows :- Symptoms. in 1916. Pensioner, age 33. Rheumatic fever January, of these cases is Advanced from the in with V.D.H. In Early diagnosis important. Discharged army June, 1916, cases of with well-formed he contracted and received aortitis, definite, , June, 1917, syphilis, very show the and of the latter. The inadequate treatment. He was admitted to hospital on usually signs symptoms Jan. 1st, 1920, with a history of dyspnoea and attacks of symptoms and signs of syphilitic aortitis are numerous. sudden, sharp, stabbing pain across the upper part of left They are divided into those due to the actual lesion chest at intervals varying from two weeks to two months ; and those due to pressure, which latter are a late mani- occasional fainting turns ; great feeling of alarm and dread. festation. Of the early symptoms, pain and dyspnoea On examination the heart was found slightly dilated. No are the most in a increase in cardiac dullness in important, with, addition, peculiar, aortic area. A rough pre- sallow sometimes fever. systolic with accentuated first sound in mitral area. B.P. septic, look, accompanied by The have a of 130 - diastolic 96. X ray showed a normal aorta and the patients usually feeling lassitude, depression, and dread. Pain in aortitis is referred to the "pear-shaped" type of heart. Wassermann was ++ with upper end of both Harrison’s and Fleming’s technique, which positive the sternum, or beneath it, and is often anginal in character, result, accompanied by pain, dyspnoea, and great radiating to the shoulder and arms, and either constant or depression, intermittent. When referred to the it is due led one to suspect an early aortitis in addition to a rheumatic ’, apex generally mitral lesion. ’ to an accompanying myocarditis. A characteristic feature Syphilitic Aortitis. of the pain is its occurrence during the night. Often there is merely a feeling of oppression about the heart or at the This may be acute or chronic. Cases have been upper end of the sternum (one of the patients who died com- published where well-marked symptoms and signs have plained of a sudden I I catch " at the root of his neck), and this