B.A. TYD~KRIF VIR ] G E..'aESIU1NDE . LABORATORY DIAGNOSIS OF DYSENTERY. [ JULIE 11 1942. 25I
The Laboratory Diagnosis of Dysentery Occurring in South African Troops in the Middle East. By )1. H . FII'LAYSOX , B. S c . , l\ I. B ., CH.B. , D . P . H . ,
Major, S.d .J/. C., Pathologis t , J/ .E .F.
T H E primary purpose of t hi s commun icat ion is to outline the met hod s used in a So uth Af rican Hos pital Labora tory
in the Midd le East for the di agnosis of dysent ery. These met hods are base d on D.M.S. , l\!.E. T echni cal Inst ru ctions, 1941, No. 59, and on methods used by Colonel J. S. K. Boyd, H. A.M .C. , and have been very sat isfact ory.
Dysentery in the l\liddle E a st , as in South Afr ica, may be caused by h elmi nthic, protozoa l, or bact erial infecti on .
(1) H ELmNTHIc DYSEXTERy.
My experience of th is cond it ion was limited to one case whi ch was di scover ed in the course of a routine exa mina t ion of fift y­ five kitchen p ersonn el for dysentery ca r riers . The pat ient,'a nat ive from the T zaneen D istrict of th e T ransvaal, was inf ect ed with Schis to soma man soni. The large lateral spine eggs of the parasite were very num erous. and were eas ily detected in the mu cus in the stoo l und er th e low-power object ive .
In ra re ca ses homatob ium has been known to cause dysenteric symptoms. Althou gh seve n cases of in fect ion of the genito-urinary sy st em with S. lusmatob iu m were det ect ed . no. evidence of dysentery caused by th is organism was obtained.
(2) PROTOZOAL DYSE XTERY.
(a) A mab ic Dyswtery .-Elev en cases of infect ion with E. h iMolytica were enco untered. In all bu t one of these cases the naked-eye appearance of the stools wa similar and chara ct erist ic of amcebic dvsenterv, These stools consist ed of semi-solid b rown frecal m~tter \~ i t h some bloo d and bro wn mucus . The st ools were very foul -smell ing. T he one excen­ ti on was a stool from a case of douhle in fecti on with E, h i.~ tolyt ica and B. dy.<entu i,p Shiga. This stool consisted of gla iry mucus and blood and could best be likened to "sago wit h' red -currant jelly " . N o di fficulty was found identifying an E. histobttica infection microscopically. F or microscopic examinat ion . a port ion of mucus fr om th e stool was washed in warm saline, and any area conta ining dark ne crot ic patches carefullv examined un der a cover-glass sealed wit h vaselin e. Th e absence of any definite cellular exudate such as is present in acut e ba cilla ry dysentery st ools was an important fea ture. " ' h ilst few polymorphs were seen , the nn mher of mono­ nuclears, macrophages and re d cell s varied in different speci­ men s. I n a few specimens C harcot-Leyden crystals were seen.
T he one ch aracteri st ic feat nr e was t he presence of actively motile arncebre conta ining red cells. Gene rally . when B. I. istol!/t ica we re foun d, they w~re numerous. Someti mes a specimen of mucus f rom a stool disc lose d one amoeba. In such cases a second or t hi rd sp eci men oft en showed an area con­ ta ining num erous act ive amreba-,
Two important technical points were strictly observed : Firstly, all stools were brought to th e laboratory in bed -pans within half an hou r of the stool be ing passed. econd ly. a hot tle of sa line was kept co nsta nt ly in the incubator. so that t he mucus could be wa hed with warm sa line immediatelv on arr ival in the laboratorv . •
I n three cases the prpse nce of E . histoly t iert cys ts was di agno ed. T he e ca se had a pr evious hi story of E. hietobrtica infect ion. T he examina tio n for cysts wa carr ied out by rubbing up a small portion of f:Pees in a watchjrlass with a 1 per cent. solution of iodine and pota ium iodide. A drop of this suspension was mounted in th e usual manner and exam ined for t he pre sence of cys ts.
I n diagnosing the presence of cys ts no cell over 14 microns in diameter was con idered . and examina tion with th e micrometer eyepiece wa found ext re melv use ful.
(b) Flagellate Dy sentery.-T wo cases' of infection with Giardia Lamblia were observed . I n nei th er case was anv blood or mucus noticed in the stool, nor was there any evi de nce of cell ular exudate. 'I'r ichomon as hominis an d Chiloma.<ti x mesnili were frequently observed in stools and on occa ion alo ng wit h E. h istolytica. N on e of these flagell ates could be accused of causing a true dysenteric co ndit ion.
(3) BA CIL UR Y D YSE :---rER Y.
This condit ion accounted for the maj ority of t he dys entery st ools ex amined . I n man v cases th e condition wa s of a mild nature and amounted to ~ " diarrhrea", or what is k nown in the Cape as .. appelkoos siekte" . The na ked-eye ap peara nce of th e stoo ls was characterist ic. I n these mil d cases t he stools were of large volu me, wat ery and pale brown in colour . Small flakes of mu cus were pr esen t but no macr oscopic blood was evident. '
I n the more sev ere conditi ons th e st ool consisted of blood and mucus. Few of our cases sho wed much macroscopic blood. T he presence of copious blood is usually an indica tion of .higa in fection. Only one case of B. dy sellt eri,,' ltiga infec­
t.ion was encountered . I n a fe w cases of more sev ere dvsenterv th e stoo ls were
watery , of a yellowish-bro wn colour, ' and co ntained flakes of mu co-pus and greenish shreds of mucus.
T he microscopi c appearance of t he sto ols was extremely chara ct er ist ic. In a high propor t ion of cases an immedi at e di agnosis of the condition was made fr om the microscopi c examina tio n an d a repor t forwarde d at once to t he ward . I n t his way corre ct treatm en t was in stitu t ed at the earl iest poss ible stage of th e infection . A flake of mucus was selecte d fr om t he stoo l and examined in saline un der a cover-glass. The outs tanding featu re of t he microscopic appearance was t he . cellul.a r ity of th e field. The number of red cells present varied WIth the mucus selected, e.lJ. a clear piece of mucus showed few red cells, a blood-sta ined shred showed man v. ~\part f rom th e red cells, at least 90 per cent. of the rema in­ IlIg cell s wer e pus cells. A ma ll n umber of epithelial cells macropha.ge? an.d eosinophils were also present, but th~ characterist ic picture was tha t of an acut e inflamrnat orv exu date, and was a typical .. ba cillary exndate". •
In more ad van ced cases the number of pus cells decreased , mor e mononu clear cells were een and erv throcvtes became fewer. T his type of exudate wa s known 'as an' .. ind efinit e exudate " and was o f no diagn ostic valu e as an indi cat ion of baci lla ry dys ent ery , in view of its resembl an ce to th e exu da te found in amoebic dy ente ry. tools showin g an .. indefinite exudate " were . however, cult ured , and fr om a certa in port ion dysentery bacilli wer e isolate d.
It is essen t ial th at abso lute ly fresh stoo l specimens should be submitted for examina t ion if a high percen tage of isola t ions are to be obtai ned. I nst ruct ions were, th erefore. i. sued that a ll " d ia rrhreic " s tools sho uld be submitted immediato lv to th e lahoratory in a bed -pan, and that on no account sliould more than thi rty minutes elapse betw een the passing of the stool a nd its a rr iva l at the lahoratorv.
T he pr esence of cresolie d isinfectant in the bed -pans was found a t one st age to inhibit ha ct eri al growt h. Th is was remed ied by th oroug h washing of t he pans in hot wat er a nd sub stituting chlor ide of lime for r-resolic di sin fectant.
Cult ures were mad e on )l cConkev's medium. whi ch was preferred to litmus-lact ose-tau rocholate agar. A portion of mucus was fished from th e stoo l a nd well washed in ste r ile saline to ~et rid of excess H. coli . Tt was th en r ubbed on th e surface of th e plat e. The plat inum loop was th en flamed and th e rubhed ar ea touched wit h th e loop . with which a second area of th e plat e was st roked. Frequ ent ly t he loop was aga in t1 arned and th e second st rok ed area touched with the loop. and from this inocula t ion a th ird area st roked . I t was found t hat with . this techn iqu e one ha lf of a 3 ' ·inch ~ l cConkev plate could be used for each stool, although it was prefera ble to use one plate for each stool. T he need for washing mucus be!ore plat e inoculat ion .cannot be over-e mphasised . U nless t his proced ur e wa. ca rr ied ou t . the isolat ion ra te dropped almos t to zero . The plate was incu bat ed overn ight at 37° C. T he colonie of d~·sent.ery bacill i wer e usually eas ily recogn ised as non-la ctose-fe rme nt ing, small, translucen t. del icat e colonies with a regular out line. Occasion allv woolI.-' irregula r colonies of fJ: dysentPT i(~ , onne were observed. 6n some pla te the colon ies were so n umerou tha t it was po sihle to carrv out a di rect agglutin.at ion te t. I n the majority of cases s electNI colonies wer e picked off an d inocul a ted on to a econd McConkev plate. using a met hod suggeste d bv Capt. l\lanifold , T.M. . '
Ir~ th is method a. l\lcConkey plate is divid ed up in to 36 sectio n hy cross-ruling t he gla ss wit h a grea se penci l. One st rip conta ini ng six sect ions is used for each sub -cult ure and one of six colonies from each original )lcConkev plat e is inoculated on eac h secti on. T hu s ix colonies fro~n each of
252 J UL Y 11, 1942.] L ABOR AT OR Y DIAGNOSIS OF DYSE N T E R Y. [ S.A. MEDICAL
JOURNAL.
directly at the bedside. Two strains of B . dyswterice Pl ex ner wer e isolated from scrapings left in glycerol-saline and one strain of the same organism was recovered from a plate made at t he bedside.
DISCU SSIOX.
T he method s used in the exa minat ion of 134 stools from 125 pat ients suspected of dy sentery have been outl ined ab ove. It is cla imed t hat t hese methods ha ve proved very sa tisfact ory in view of t he result s ob tained. The cr it er ia used in th e diagnosis of a meebic dy sentery, .via., (a) t he pr esen ce of act ively mot ile amoeb.e, a nd (b) the presence of erythrocytes in t he se amoebte, led t o t he di scovery of elev en cases of active a rnoebic dysen tery or 9 per cen t. o f the total number of cases investigated. T his high proport ion of amcebic dysentery is expla ined by t he fact that the maj ority of th e patients ga; 'e a previous history of amoebic dysentery cont racted in the Union o r in th e E ast African Campaign.
Only three patients were found excreting E. h istolytica cysts in the freces. All th ese patients presented evidence of pr evious E. h ist olytica infection . It is very doubtful if arncebic cyst s found in the stoo ls of pa tients who have given no previous history of E. hist olytica infect ion ca n be regarded as patho­ genic. Many protozoologists are of the opinion that different r aces of E. !<ist olytica exist, some of which are non -pathogenic to man. Thus ' Brumpt (quoted by Mansou-Ba hr , 1940) recognises a .. physiological species " mor pho logi cally in- di stingu ishable f rom pathogenic E. hist olytica. •
The majority of cases of dysentery wer e bacillary, and organisms of th e Fl exner group formed the highest proportion of isolat ions . By ca refully washing flakes of mu cus bef ore inoculating pl ates of media, a high percentage of isol ations was obta ined in cases showing a •. bacillary exudate " . This isolat ion rate com pa red well with that reported by Anderson and Cruicksha nk (1941). These workers, investigating an out­ break of F lexner dy sentery and usi ng a specially selective medium for Flexners ba cillus, reported an isolation rate of 97 per cent. fr om the stoo ls of 35 patients examined during t he second to t he fourth day of t he diseas e, and 83 per cent. isolation f ro m the stools of 18 patients examined during t he fif t h to th e seventh day of t he di sease. As t he ma jor-ity of ou r pat ients a rr ive d in hosp it al fro m th e th ird to the se ven th day of t he di sease, our isola ti on ra t e of 86 per cent. f rom 38 pat ien ts showing bac illary ex uda te may be considered satisfactor y.
T he isolation of B. dysenteriw Fl exuer f rom th e stoo ls of tw o members of the kitchen per sonnel in the cour se of a routine examinat ion was of considera ble interest. Both patients exhibited stoo ls showing an .. indefinite exudate " . N either a ppeared ill or appeared to consider t he ir stools abnormal. T hese cases were probably suffering fro m chronic d vsentery a nd t hey were obvious ly not suita ble fo r employment' in the hosp ita l kit chens. Sporadi c cases of dy sente ry ha d occurred at intervals amongst the hospita l sta ff. Al t hough it was not possible to trace an)' di re ct relationsh ip between t hese ca rr iers a nd such cases as d id occur, it was noted that fewer cases o f dysent ery occur red. amongst the hospital staff after t he two carrier s had been Isola t ed and cured .
T he case of Sc h ist osoma mal/.wni infect ion detected in a South Af rica n na t ive in th e course of rout ine examination for ca rriers ra ises an in teresting problem in public hea lth. This native ca me fr om th e T zaneen d istri ct of th e T ra nsvaa l, and a ppa rent ly ". man soni infect ion of natives is not uncommon in this d ist r ict. J ust as ". h rematobium: infection has gradually spread down th e East Coa st of the Union , so may we expect S . manson i infect ion to sp read if a su itable snail host becomes infect ed wit h th is helmin th . I t would appear worth wh ile, wh ilst this infect ion is comparati vely loca lised , as it is at present, to t ake strenuous meas ures in an attempt to sta mp out S. manson i in fect ion in th e Union.
U) DIAR Y.
(1) One hu nd red and t wen ty -five cases o f dysentery were investi ga te d in a South A fr ica n q eneraI H osp it al in th e Middle E ast : 38 ca ses s howed a .. bac il lary exuda te " di agnostic of ba cillary dysenter y, 57 cases showed a n .. ind efin ite exudate ", whils t 30 cases showed no exudate.
(2) E leven of t he ea es examined . or 8.8 per cent . , were fonnd to be inf ect ed wit h 1-:. h isf olyt ica.
(3) T hree cases were fon nd to be passi ng E . h i.~ tolyt ica cysts. These cases all showed evidence of previous E. h i.~tol!ltica
in f ect ion.
six stools can be inoculated on one .McConkey plate. The plate is in cubated over night and non -lact ose-fermenting colonies can be clearly di stinguished. Direct agglutination tests using group sera can be car ried out and the type of organism readi ly Iden tifi ed . Confirma to ry bioche mica l reacti ons usin g lactose, glu cose and ma rmite pep tone wat er can th en be done, using inocula tions f ro m th e plate colon ies.
T he d irect a~glu tination te st s wer e car r ied out by mak ing I
a thick suspensIOn of the organ isms in saline. Five drops of this suspension were placed On a glass sli de. One drop of Shiga , Schm itz, Sonne, Flexner 1 and Flexner 2 polyvalent anti-sera r esp ecti vely wer e adde d and mixed wit h the d rops of suspension. The slide was then rocked for a few mi nu t es. P ositive re sul ts wh ich wer e easily seen naked-eye develop ed in a bout five minutes. The mixtures whi ch did not agglutinate served as cont ro ls .
The "Flexner " poly valent se ra used were pre pared agains t the f ollowing strains :-
Fl exner I-B. dysenteria: .. . . .. .. . Fl exner 1 2 3
Flexner 2--B. dysellt er ill . .. . . . . .. Flexner 4 5 6
Boyd 1 Occasionally st rains were isolat ed whi ch d id not agglutinate
with any of the type sera, although they con formed in morphology and biochemical reaction wi th organisms of th e dysentery gro up. Su ch strains wer e further mvestigated bv inoculating t ubes of lactose and saccharos e pepton e wat er, sea ling with paraffin wax a nd incubating for three week s. Most stra ins fermented lactose before the end of this peri od. One strain investigat ed in this manner pr oved to be B . dys pnteri,c Sonn e.
The following t able summarises th e results of a n in vest.iga­ tion of 125 cases of dysentery by t he method s outline d ab ove :-
TA RLE.
Number of suspect ed cases in vesti ga ted 125 Number of stools examined .. . . . . .. . . .. 134 Number of cases in which .. bacill ary exudate" wa s
present . . . . . . . . . . . . . .. .. . .. . . . . ... . . . . . . .. . . .. 38 N umber of cases in which " indefinite ex udate " was
prese nt . .. .. . . .. .. . . .. .. . . . . . .. .. . . .. ... 57 N umber of cases in which no ex udate was present 30 Number of cases infected wi th H. dysellt erio Shi[la 1 N umbe r of cas es infected wi t h B. dysellt eri,,' Sch mit z 4 N umb er of cas es inf ect ed wi t h B . dysclIteri,,' S onn e 2 N umber of cases infecte d wi th B . dyscllterilC Ft ez ner 42 Total number of d ysenter y stra ins isolat ed . .. . . . . .. 49 P ercen tage of cases showing ex udate fr om wh ich
dysentery st rains were isolated . . . . .. . .. ... . .. 53 % N umber o f cases showing "bacillary exudate " from
whi ch dysentery st ra ins wer e isolated . .. . .. 32 or 84 % N umber of cases showing " indefini te exudate" f rom 0
wh ich dysentery stra ins were isolated 17 or 30 ~~
It will be not ed that although no spe cial select ive medium was used , t he isolation rate fr om bacill a rv ex uda tes was ver v satisfactory, '"
Carriers.-A rou t ine exa minat ion of kitchen per son nel was ca rr ied out in an attem pt to detect enteric an d dv senterv ca rr ie rs. T h ree stoo ls from each member of t he 'h 05pit il kit ch en st a ff wer e examined. Altoget her fifty-fi ve members of the st aff wer e investi gat ed. T he maj ority of th e stools were formed or semi-formed, an d wer e, ther ef ore useless for ex amina ti on for th e pr esence of dysentery or ga r;isms. A fe w " loo~e " stools wer e fu r th er invest iga ted by the methods de scr ibed , a nd fr om two of th ese B . dysellterirc Fl ex ner was isolated . N ei th er of t hese ca rr iers. one a Xative and th e ot her an Italia n P .O.W., re porte d ill at any time or appe ared to consider th eir s tools to be in an v wa y abnorma l.
Chro llic J)J/sl' lItuy.- In t welve cases o f chronic dvsenterv on wh om sigmoidoscopic exami nat ions wer e carr ied out th e bQwel app earan ce suggested a chro nic bacillary infect ion. Scr a pings of th e bowel wa ll were placed in a small bot t le containing 30 per cent. gyce rine in nor mal sa line ad j uste d wi th phosphate buffer to Ph. 8, and sent to the la bor atorv. McConkev pla t es were inoculat ed immed iately on arr iva l of "t he spe ci men at t he lab or atory . I n some cases th e :\IcConkey plate s were inocu lat ed
S.A. TYDSKRlF VIRJ G ENEES KU NDE. FOOD INFECTION. [J ULIE 11 1942. 253
(4) T hir ty -t wo of the 38 cases sho wi nc .. bacilla rv exuda te .. y ielded dysentery bacilli on culture . 0 •
(5) E. dys enler ia: Fl ex n er was iso la te d in t he majority of cases . B . dys enler ;;I' :;1,if/a, S clUII;t: a nd S ou ne were ' a 'so encountere d.
(6) A routine examina tiou of 55 suspec ted ca ri-iers viel de d two cultu res of B . d y s ellt er ill l Iexner, an d iu ou e case S. mansoni ova were ident ified .
(7) B. d y senl er ;le Fl ex n er was isolat ed fro m t hree of twelve sigmoidoscope spec ime ns sub mitted.
ACKXOWLEDG~IEXTS .
I ha ve to thank Brigad ier A. J . Orenste in, D. ~I.S . , D.D.F. . fO,r permission to publish this . pa per, ~nd al so S JSgts . Lombard , \\ ellsted and T albot for t heir technical assis tance.
BIBLIOGRAPHY. Anderson, D. E. tr ., aml C rui d 's han l' , R. (1941) : Il rit islc
.11edical J ournal , 497. .11anso n .B ah T
l P. H . (1940) : T rop ical Diseases, page 859.
D.M .S. , M.E. (1941) : T'echn ical ! IIS/TUC/ ioIlS, .\"0. 59.
The Antigenic Structure of the Bacteria Incriminated in Four Unrelated Out­ breaks of Food Infection.
By ~1. W. H ENNING, )I.R.C.V.S.. D.Sr.. . UNDERSTEI'OORT.
A STUDY of the ant igenic str ucture of four species o f Sa!mon ~lla .conc~rned I!I outb rea ks of food-i~f ection (so ­
called food -poisoning ] m t he I'ra ns vnal, was made III colla bora ­ t ion with Dr. J ames Gear of ~ he Scuth African Ir st itute of Medi cal R esearch .
Deta ils of the d iffer ent ou t brea ks are gln~l bv Ge ar R oux and Bevan in the preceding paper in th is .ssue, 'r he te /hn iouc described hy H enning (1939) was employed, •
Previous out breaks of Sulmoneltn f~o,l - infection ill Sout h Africa wer e descr ibed by Greenfield an d .Iud d (1936), H enning and Gree nficld (1937). H enni ng (1938) . Bncha nan an d Bevan (1009) an d H en ning , Rh od es and Gordon-Johnstone (1941).
OUTBREAK I OF GEAR. Roux AND BEVAN (CULTU RE 1003). A non-lactose ferm ent ing Gra m-negati ve orga nism isolated fro m the fn-ces, th e vom it. ~nd th e blood of the affe ct ed pat ien ts re vea led . on a pr elimina ry study , all t he cha ract ers of a Sal".lOn ella , a nd was found to fall in Group C of t he K a u ffrnnn n ­ White Schema. B y mean s of agglutinat ion t est s it wa s observed that cu l t u r~ ~003 was ~Iiphasi c an d tha t, .it ~ccur re<! in the a -fi phase va r ratron of K auffm a nn a nd ) d tslll (1930). It was agg lu tinated by se ra cont ain ing facto rs P'" en an d enx, b ut whe n a number of si ngle 18-homs-old colonies were t ested some of the colonies wer e more read ily floccul ut ed b v eh sera while ot hers wer e agglutinated better wit h sera couta ining ei ther facto rs en or en.x.
For fur t her st udy pure fI/-': an d eh sera "Yere therefore pre. pared by respect ively absor bing ab ort ns-rqui serum wi th eas t ­ bou rn e specific (cont a ining factors eh) a nd r ast bourne sp ecific serum with abort us-equi (containing fa ct or s wx ). It was not conven~en t to obta in a pu re ell serum and the pure PlIX serum was SUIta b le for purp oses o f the test. But it was noticed t ha t phase dissociation occurred so irregularly that it was verv di fficult to obtain an antigen that was pr esent in either t he a or p phase in t he pure state. By empl oyin & cot ts (1934) t echn iqu e for the acceleration of phase di ssociat ion improved bv W assen (1935) and Bruner and Ed wa rd s (1939. a and b) t h isxlifficu ltv was .overc ome and it becam e possible to obt ai n pure ant ig ens of eit her the ao r f3 ph ase. T wo serres o f sloppy aga r tubes, of which th e one cont a ined aborlll s· eqlli serum (factor elIx ) and the othe r wB/ bourll e speci fic seru m (f act ors eh l, we re inoc ulat ed with cult ure 1003. I n each series t he t ra ns fers wer e made at intervals van' in g f rom 6 to 18 hou rs. After six to eight tran sf er s it was' possibl e to obtain a pure a (eh ) p ha se fro m th e sloppy aga r enriched with aIJOrtu"-equ i serum and a p UI ~ (enx) phase from the sloppy agar cont a ining ea.•t bmlT lI c serum. From t hese phases it was possible t o obtain antigens wbich react ed on ly with pure sera of the same phase and not
with pure sera of t he oppos ite phase -i .e . a -p hase a nt igens reacted only wit h pu re eastbourn e specific se rum from whi ch the common fa ctor wi th a bort us-eq ui (e"x ) was removed by ex hau~tion wit h abort us -equi an d t he fi-p has e ant igens were ugg lut.in ated only by pure ahort us-equi serum fr om which t he overlapping factor (ell ) with eastbour ne was re moved bv abso rp - ti on with eas t bourn e specific. .
After th e preparation of pure a and fJ phase ant igen s ag glu t i­ na t iou an d ab orpt ion t est s wer e performe d :-
. • U " al//;gel/ : Cu lt ure 1003 rem ove d all the " 0 .. , gglut ini ns from sera li ke choleru -suis whi ch conta iu I uctors \ '1 an d VI I. while chole rie-sui.• com pletely exhaust ed th e .. 0 " aggtut in ins from 1003 serum. The " o ': ant igens of culture 1003 an d chol era -suis must, t herefor e, be regarded as iden ti cal.
.. 11 " an t.uje ns : Or ganisms like eust bou rn e (specific phase) wh ich cont a in factors eh nearly complet ely exhausted t he a -phase (eh ) from 1003 ser um without mat eri ally a ltering the {3 -phase (fa cto rs ell or ell x ), whereas a bact erium like gl os/ru p (s pecific phase ) contai ning Iactors ell but not ch r em oved nearl y a ll the fJ·phase ag gl uti ni ns f'rom 1003 se ru m.
T hese te sts ind ica t ed t hat cu lture 1003 was closelv related to S. h ruen d er up , T he recip rocal ab sorption t ests that were now perform ed with brue nd eru p a nd cult ure 1003 confirmed these observa t ion s. Cult u re 1003 removed a ll t he .. U " . a (facto rs ell ) andfJ (t act crs cn ) phase ..ggru riurus fro rn brurntt eru p serum, while braetuleru p completely ex hau st ed H.03 serum. It was theref ore eviden t t hat cult u re 1003 and brae,II l trllp were identi­ ca l , conta ini ng t he same antigen ic component s , vi z. , VI , V II­ eh : en.
OUTBREAK 2 OF GEAR, Roux ASD BEVAN (C ULTURE 10(2). An organis m o f th e S almon ella group was isolated f rom the urine a nd freces of a numb er of the pa tients.
P reliminary tests sh owed t hat cult ure 10:12 fa lls in Group C of th e Kauffma nn-W hit e Schema. W hen it was ca refully examined by mean s of aggl utination and absor ption test s its ant igeni c st ruct ure was found to re sem ble t hat of cult ure 1003 and braend erup. Culture 1002 was, t heref ore, also given the antigeni c assignment of : VI . VII - eh : ell .
As in the case of cult ure 1003 , a - fJ phase d issociation could not he brought a bout sat isfactor ily withou t th e employme nt of Scotts (1934) t echniqu e, mod ified by W assen (1935) and Bru ner an d Edwa rd s (1939, a an d b )_ T he bioch emica l reaction s of cult ures 1002 an d 1003. however, re veal ed min or di fferen ces (T a ble I ). .
OUTBREAK 3 OF GEAR, Roux ANI> BEVAN (CULTU RES 1000 AND 1001). Id en t ical cult ures (1000 and 1001) were isolated from the vomit an d stools of a number of patients a nd fr om th e i::cr iminat ed me: t. By 1" 1'1 mina : y t esting these wer e found 10 \;1' Sulm onella » faIlinl( in G,'oup J) of Ka uffmann-\Vhit e Sch ernn. By per-forming agglutinat ion ab sorpt ion t ests cult ure 1001 was foun d tu rem ov e a ll the .. 0 " ag gl utinins fro m e n t e rit u lis as well as d u b l i n sera . wh er eas eith er d u b l i n or e n te ri t id is exhau -t ed th e soma t ic agg lut inins f rom 1001 serum.
Bot h du/,/in and en te r it id is se ra aggluti r-at ed the" 1I .. ant i , ge n o f 1001 to full t it re, hut cult u re 1001 failed to exhaust t he .. 11 .. agg lut inins from du hlin se rum ; it mere lv reduced t he titre f ro m 12,800 to 6,400. Cult ure 1001, howev er , corn­ plet ely abso rbed a.ll th e " 11 .. as well as the " 0 .. a gglut inins from r n t n i / id i.' serum (t it re " 0 .. = 800 and " 11 .. = 12.800) . W hen 1001 se rum (t it le .. 0 .. = 800. .. H .. = 6.400) was ab­ sorbed hy esve rit id i» and d ublin se pa ra tely, en te r it idis re moved a ll th e flagell ar as well as th e somat ic agglut in in s. whe rea s dub/in only absorbed th e so ma t ic agglutini ns , leav ing t he t it re of t he fla gellar ag gluti ni ns pract icnlly unaltered.
It was th er efore clear that cul t ure 1001 was id ent ical wit h en t erit id is conta ining the sa me an t iuen ic compon ents , viz. , lX- gm . •
OUTBREA K 4 OF GBR. Ro ux AN n BEVAN (CULTURE 1016). A p r-elimin a ry t ud y of th e o rganism isola ted f ro m the excret a o f a numher of patien t s a nd a l 0 f ro m scr aps of ra w mince · meat in crilll inat l'd sh owed tha t t he\' were id ent ical Sal m ollell ll8 occ uni ng in G roup B of t he Ka u·ffma nu·W hite Schem a. The orga ni illS were a pparent ly rel at ed to / y plt i.m ur ium. Agglut iuat ion altd absor pti on t est. sho wed t hat cult ure 1016, a lt houg h complet ely exba us ti ng the .. 0 ,. agglu t in in s from
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