mmr3ba 354 3DIGTa JoVl) IJ THE ENTERICA GROUP.7 ([JULY 29, 1~z'8 or, I (c) With a prodromal rise of temperature for three TIlE_WAR. to five days, after which the temperature comes to normal for one to four days, and then the fever runs its prolonged course. " THE ENTERICA GROUP." (d) Simulating acute appendicitis, witlh Vomiting. A DISCtUSSION on the Enterica Group tock place at a recent Some ten or a dozen cases were operated on and the meeting of the Anzac Medical Society at Cairo. appendix removed. The inflammation of the appendix Lieut.-Colonel WALTER SUMMONS made a report on the was part of a general inflammatory condition of the cases of enterica at the lst Australian General Hospital intestines. at Heliopolis. Patients suffering from long-continued (e) With symptoms of acute gastro-enteritis. fevers were, he said, being met with in the medical wards (j) With signs and symptoms of pneumonia. from August, 1915, onwards. The agglutination blood tests did not give a positive Widal reaction to the typhoid The course of tlle fever in many cases was prolonged, bacillus, yet the clinical picture was similar to that of an and though the patient progressed favourably still the infection witlh this organism. Arrangements were then temperature ran into the sixth week before it came to miade with the Laboratory of the Institute of Hygiene, normal. The type of. fever was irregularly intermittent. Cairo, for the examination of the blood of these febrile Relapses were not uncommon, with a repetition of the cases. The staff of the laboratory had recently been signs and symptoms, but milder in dearee. Headache at augmented by Captain Hutchens and Lieutenant Myat, the onset was a distressing symptom, but this passed off two English bacteriologists. All tlle cases were Australians, in the fi-st week, and after passing througlh a lethargic and one can assuLme that all had been inoculated twice stage of varying duration the patient becalme bright and wvitlh antityphoid vaccine witllin the twelve montlhs prior had few troublesome symptoms. As a rule the patients to infection, and also that the patients had not been lost weight, but not to the extent of cases of true typhoid. inoculated with paratyphoid vaccine. For the blood tests From the rarity of serious complications and low mortality five cubic centimetres of blood were witlhdrawn into a figures one was inclined to allow more food. Distension syringe from a vein at the bend of tlle elbow as soon of the bowels and undigested food in the stools readily as tlle clinical picture was one of suspected enteric. The yielded to treatment. Apart from the occasional initial blood culture was only of value in the first ten days of the diarrhoea the bowels were constipated 'and relieved by illness except in tlle occasional case wlhen the organisms enemata. One of the early patients died of haemor. persisted, and in these the symptoms were severe. rhage, but this was before the nature of tlle fever had been recognized. Less than 1 per cent. Blood Examintations at thte Central Laboratory. of the cases had melaena; of the spleen Blood cultures * Agglutination tests: enlargement + Paratyphoid A ... 40 + Paratyphoid A 7...7 was an almost constant sign. Of the sequelae. the + Paratyphoid B ... ... 12 + ParatyphoidB ... 18 cardiac affections took a prominent place. Myocardial + Typhoid. 5 + Paratyphoid A and B 2 weakness was common, and demanded prolonged con- Total... 57 ~~+Typhoid(strong) ... 28 .Total . ......+ Typhoid (weak) . 37 valescence. The pulse not infrequently did not become 1Tegative results ... ,, 128 Negative results 63 rapid until the patient had been allowed up. Less fre- Total cultures .., 185 Total performed .,. 225 quently a gross arrhythmia was found, and these cases did not improve till after a prolonged rest in bed. A few Not a few returns came back thus: Weak typhoid and cases of polyneuritis were seen, but more cases of limited + paratyphoid A or paratyphoid B. These are counted neuritis came to us amongst the convalescent patients as paratyphoid A or paratyphoid B respectively. In view transferred from other hospitals. Phlebitis, cholecystitist, of the rarity of + typhoid in the blood cultures, it is and nephritis were less common complications. Few evident that the agglutination test of B. typh7wsu8 is not soldiers, he thought, would suffer permanent damage as an index of actual infection with this bacillus. The value the direct result of the infection, and out of the 800 cases of the agglutination test in previously inoculated patients passed through the hospital there had been only five is open to discussion. Nevertheless, in this epidemic it deaths. This, however, did not give a true idea of the seems a fair inference to assume that a + paratyphoid mortality-rate. Half of the patients had reached the con- A or B is diagnostic of disease. After a universal prior valescent stage, and not a few were in bed for other inoculation it will have to be regarded that the only reasons wlhen the bowel infection developed. Moreover, proof of an enterica infection is the finding of the actual the most severe cases from Anzac were not sent to Cairo. organism in the blood or in-the excreta. As the hospital On the other hand, there was no greater fatality-rate served the double purpose of being the hospital for the amongst the cases that came from the Garrison Force. troops training in Egypt and of receiving patients from The European and Egyptian predominating organism was the Mediterranean force at Gallipoli, fuLrther analysis of paratyphoid B; in the Gallipoli infection paratyphoid A the positive results was made. Combining the blood largely predominated. As paratyphoid A was common in cultures and the agglutination tests, the totals are: India, it might be that the Indian troops brouglht Chis M.E.F. Garrison. organism. It remained to be seen which bacillus was preva- Paratyphoid A .. 81 ., ... 34 lent amongst the Turks. The value of prophylactic injec- Paratyphoid B ... ... 7.... 23 tions with antityphoid vaccine was uplheld. A number The proportion in the M.E.F. cases is 23 to 2, and in the of typhoid cases had occurred, and doubtless from the Garrison Force 3 to 2 of paratyphoid A to paratyphoid B. nature of the position %t Anzac the percentage would have TXhese infections seem to be clinically identical. From been much greater had not some opposing influence been observations of a single epidemic it has not been possible present. The troops had now to a large extent been to differentiate the various infections except by means of inoculated against paratyphoid A and B, and tlhis, com- the laboratory tests. The clinical aspect of the para. bined with the removal of carriers, would, it was hoped, typhoid patient differs from the well known typhoid lessen the number of cases next season. picture. The patient does not look so ill, in spite of the Colonel W. H. PARKER, C.M.G., D.D.M.S., New Zealand temperature running on for weeks between 1030 and Forces, contributed, from the New Zealand General Hos- 1040 F. Tlle rash is decidedly more marked, and may be pital, Cairo, of which he was O.C., statistics of enteric so distributed that at first glance one thinks of measles, cases examined between November 1st, 1915, and February but the spots are only on the trunk and limbs as far as the 20th, 1916. elbows and knees; they are pinkish, not confluent, and Incidence.-The typhoid figure was slightly below, the vary in size, but usually are larger than the spots seen in paratyphoid A much above, and the paratyplhoid B much typhoid. Again, the spots often appear late in the disease, below, the figures given in the memorandum recently during the third week, and when the fever is defervescing. issued of results obtained in the laboratories of Cairo, Many of the attacks came while the men were in hospital Alexandria, and Mudros: N.Z. Memoranaum. for surgical ailments, and thus the first signs could be Total cases examined .170 ... Observed. The mode of onset in order of frequency was- Causative organism isolated in .. 34 per cent. ... Due to typhoid bacillus ... 10 ,, ... 11 (a) Gradual with severe headache that persists for Due to paratyphoid A ... .. 73 , 44 a week and an increasing daily rise of temperature. Due to paratyphoid B ... ... , 17 ,O ... 45 (b) With rigors and high temperature from the start, Place of Origin.-The cases classed in the following that shows little remission. table under the head Gallipoli includes those developing JULY 29, £I1 CASTALTM9 IR tlft2 IMfBlYCAL SERYVICES. =MxDIoALJOW.A. r5 enteric shortly after their return to Egypt; but the large received his medical education at St. Thlomas's Hospital,' number of cases direct from Gallipoli may account for and took the diplomas of M.R.C.S. and L.R.C.P.Lond. inl many failures to isolate the causative organism owing to 1905. He was house-surgeon to the East London Hospital the period of disease oni examination: for Children, Shadwell, and house-physician to the Wesf Gallipoll. Egypt. London Hospital; afterwards he went to South Africa Total enterics ... ... 89 Of which there were due to typhoid.5 and after serving as medical officer of the Beira railways, Paratyphoid A ... ... ... ... 24 . 18 began to practise at Buluwayo, the chief town of Southern Paratyphoid B ... 1 9 Rhodesia, where he was medical officer of the Buluwayo The majority of the typlhoid cases were from Gallipoli, Government schools. He took a temporary commission as but 9 out of 10 of the paratyphoid B were local cases. Lieutenant in the R.A.M.C.