AN ACUTE EPIDEMIC OF GASTRO-ENTE. RITIS ATTRIBUTED TO FOOD-POISONING.

CAPTAINS HUGHES &

HEALEY: EPIDEMIC OF GASTRO-ENTERITIS.

that the injection treatment was used again At present sufficient time has not elapsed to enable me to form a reliable forecast of the ultimate In Case 5 a slight recurrent pain was felt result. in March, 1899, but soon subsided ; in July another attack of the same kind occurred but soon passed off. It must be borne in mind that these two cases were on the whole the most advanced and apparently the most hopeless of the series and the important point must be especially noted that the pain in Case 4 was not a true recurrence but a new development affecting a different area. Since the date upon which the lecture was delivered I have operated upon two other cases the progress of which has been precisely the same as those already given, no sign of recurrence of pain having up to now shown itself.]

distressing in August.

1223

then irregularly intermittent, oscillating near the normal line for some days before convalescence. Two of the patients had mild relapses of gastro-intestinal irritation and pyrexia lasting for three or four days, following the first solid food taken in one case and in the other coming on when the patient left his bed. In several cases vision was temporarily obscured and in those cases epistaxis occurred. The pulse was at first rapid and full but later it became slow, feeble, and even intermittent, the immediate cause of death being heart failure with a subnormal temperature. During convalescence, which usually set in from the seventh to the fourteenth day and was slow and protracted, the appetite

became ravenous. Treatment and dietary were chiefly symptomatic, aiming at the removal of the cause per rectum, mitigating the intestinal symptoms, and keeping up the patient’s strength. Bismuth,

opium, atropin, digitalis, strychnia, thymol, &-c.,

AN ACUTE EPIDEMIC OF GASTRO-ENTE. RITIS ATTRIBUTED TO FOODPOISONING. BY

M.

LOUIS

HUGHES, L.R.C.P. LOND, M.R.C.S. ENG., D.P.H.

CA TAIN R.A.M.C., ASSISTANT SANITARY OFFICER, ALDERSHOT;

AND

C. W. R. CAPTAIN

HEALEY, L.R.C.P. &

S. IREL.,

R.A.M.C., CAMBRIDGE HOSPITAL, ALDERSHOT.

were tried. The cases were at first attributed to the effects of marching in the sun. No emetics were given. The post-mortem appearances in the three fatal cases consisted of intense congestion, inflammation, and oedema of the mucous membrane of the stomach and small intestines, varying in degree and locality, but in one case involving the stomach and the whole of the small intestine. Peyer’s patches were practically unaffected, but the solitary glands were congested and prominent. There was no ulceration or visible entozoa and the colon was unaffected. In one case the small intestine contained loose terra-cotta coloured fsecal material. The liver, which was enlarged (from 70 to 78

ounces)

and

bile-stained, showed signs or fatty degeneration.

DURING August and September last more than 30 patients, The gall-bladder was full but not markedly distended. The the subjects of acute gastro-enteritis, were admitted tc, spleen was normal. The kidneys were enlarged and intensely , congested ; the capsule was non-adherent. In one case the hospital at Alderahot suffering from a combination of cortex of both kidneys contained small cysts filled with clear : jaundice, pyrexia, and other symptoms which were strange fluid. The skin and other tissues were deeply bile-stained. to ourselves and to those whom we have had an opportunity The lungs were congested posteriorly. The thoracic and of consulting. abdominal lymphatics were not noticeably enlarged. The In a few cases the onset appeared to be sudden, the men muscles of the legs, the throat, the diaphragm, and the feeling giddy, and in two instances actually losing conscious- ileopsoas were free from triuhina or other parasites. The In most instances, however, there was a preliminary following cases are given as illustrations. ness. CASE 1.-The patient, aged 22 years, whose previous health stage of malaise, pains in the legs, headache, and thirst, gradually leading up to the more acute symptoms. One had been good, complained of headache and pains in the man, though 11 seedy," did not come to hospital for ten days. calves on August 27th at Cowshot Camp and was All suffered during the early stages from pains in their admitted to hospital on the next day with pain in limbs and headache, followed by anorexia, pain in the the epigastric region followed by vomiting and jaundice. stomach, nausea, and then vomiting. All were constipated He became deeply jaundiced on Sept. lst, on the at first, but this gave way (after aperients had been given) to 2nd severe vomiting set in, and on the 3rd there diarrhoea with peculiar loose, slate-colonred stools. These was hasmatemesis. The jaundice increased, the pulse became feeble and at times intermittent, and diarrhoea were in some cases mixed with altered blood materials, set colour to them a terra-cotta black in, with loose stools containing altered blood material. (changed giving when bismuth was being taken). In two cases malaria The vomiting was checked by opium, but it returned on the occurred. On reaching hospital from six to 30 hours after 4th and became very violent, several pints of fluid being the onset of the attack the patients were found to be suffering ejected, some containing blood. The patient sank rapidly from pyrexia, the temperature ranging from 101° to 1040 F. about midday and died from heart failure. The treatment The tongue was furred, with a tendency later to dryness was symptomatic, with opium and later stimulants, Post-mortem examination 26 and a brown centre, abundant diaphoresis, great thirst, total digitalis, and strychnia. anorexia, and pain and tenderness of the abdomen, most hours after death showed the skin and other tissues much marked in the epigastric and hepatic regions, were present. stained with bile. The heart and the leftlung were normal, There was nausea, followed by continued vomiting and in two the right lung having a large patch of basal congestion. The The urine was scanty, highly liver weighed 78 ounces; it was greasy to the touch and was cases by actual hasmatemesis. coloured, in most cases containing granular casts and traces easily broken down. The gall-bladder was full but not overof albumin, and in some abundant crystalline phosphates. distended. The spleen was not enlarged and apparently Muscular pains and tenderness (most marked in the calves of normal. The kidneys were enlarged and congested. The the legs) were prominent symptoms. The tendon reflexes stomach was in a state of acute inflammatory congestion There with oedema of the mucous membrane and signs of recent were diminished and in many cases they were lost. In all severe cases gradually haemorrhage. The duodenum and the upper part of the was much loss of body weight. increasing general jaundice appeared in from two to five jejanum also were acutely inflamed; the solitary glands days, increasing up to about the tenth or fourteenth day and were prominent but there was no ulceration. (From notes then fading very slowly during convalescence. In a few taken by Lieutenant H. E. Haymes, R A.M.C.) cases this persisted for a month and more. In some instances CASE 2.-The patient, who was 21 years of age and who it merely tinged the conjunctival membrane, in others it had previously had good health, was a teetotaler. He left became severe and general. It is interesting to note that Aldershot with his brigade on the morning of August 24th in the two fatal cases with extensive gastro-duodenal for Barrossa Camp. On the 26th he marched to Cowshot inflammation, jaundice was an early symptom, while inI Camp, where he first began to feel " seedy" between 11 P.M. the one in which this inflammatory condition was and midnight while on outpost duty, with headache and most marked in the lower portion of the small intes- stiffness in the calves of the legs. On the morning of the tines jaundice did not appear until the fifth day. In 27th (Sunday) he felt worse and his nose bled at 11 A.M. all cases it was a very noticeable symptom. Seven suffered He lay down all Sunday, but did not sleep at night on from herpes on the lips and face, and four from a general account of headache and pains in the legs. He did not urticaria lasting for two or three days. In severe cases, hypo- vomit. On the 28th at about 6 A.M. he was seized with static pneumonic congestion was present. Headache was a vomiting, but he managed to march to Pirbright (one mile) persistent symptom and was combined with drowsiness and when he fell out. He then marched behind a water- cart to mental confusion, restlessness, and insomnia, especially in Ash (four miles), where he lay down for a short while and the early stages. The temperature was extremely irregular, then was sent in an ambulance to hospital. On admission being high and remittent for from four to seven days and (August 28th) he suffered from persistent thirst, severe pains ,

,

1224

CAPTAINS HUGHES &

HEALEY: EPIDEMIC OF

GASTRO-ENTERITI.

A large number of articles of tinned and of ordinary food in the legs, followed later by epistaxis and frequent vomiting. There were pain and tenderness over the epigastric region and supplies, articles of food and drink supplied by hawkers, were considered with decidedly negative the liver and total anorexia. Jaundice set in on the 29th mushrooms, &c., and increased gradually up to Sept. 3rd, and though fading results, the principal ones common to affected regiments, was still present on the 25th. The patient was at first con- but not common to the garrison at large, being those stipated but this condition was relieved by castor oil. supplied by the grocery contractors. The great number of Diarrhoea with loose slate-grey stools followed. A herpetic cases occurred while the lst Brigade were out in camp at eruption occurred on the lips on August 28th and epistaxis Cowshot during field training. On August 24th the whole of again on Sept. 4th. The patient began to convalesce about the lst Brigade marched out after a bread-and-butter breakSept. 6th. A relapse of gastro-intestinal irritation and fast to Barrossa Camp, the regiment most affected having, pyrexia occurred on the 14th, following the eating of solid unlike the others, cheese supplied by A in their haversacks, food. Convalescence was very protracted. Jaundice was which they ate for lunch. In camp all had fresh meat, still visible in the conjunctivas on Oct. 10th, and though the vegetables, butter, bread, and two ounces of a different cheese, supplied by A, and some German sausage. patient was up and about he was still debilitated. Cultivations were made in broth, nutrient gelatin, and Next day they had similar supplies, except that preagar-agar from the spleens of all three fatal cases in from served beef of a well-known brand replaced the sausage. three to five hours atter death, twice directly, and in one On the evening of the 25th they marched to Cowshot and remained there until the morning of the 28th. On these case through a subcutaneous puncture the position of which was subsequently verified. All three proved sterile, but from tiays similar supplies were issued, only that bacon and brawn the liver and kidney of one of the former cases the bacillus replaced the sausage. All these supplies were eaten by the coli was obtained and was kindly verified for us by Dr. 3rd Brigade (in which no cases occurred) in camp on the Klein, Professor Wright, and Dr. Durham, and gave no same dates elsewhere, and similar cheeses were eaten by Sections of certain civilians without any cases arising. The cheese was reaction with blood serum from other cases. the kidney showed inflammatory changes in the tubes but no issued to be carried in the haversack on the march, but Gram-staining organisms. Blood serum from several cases, the 27th being a Sunday there was no march and much of kindly tested for us by Mr. Foulerton, gave no reaction with it not being eaten was thrown away with the refuse. At Gartner’s bacillus. The internal organs and part of the 7 P.M. on the 28th (after the troops had left the Cowshot contents of the stomach and intestines of one case were Camp) a flock of about 20 sheep was driven into the field. forwarded to Dr. Luff at St. Mary’s Hospital for analysis, At 7 A M. next morning the farmer was called to see them. who reported: " Quite free from all metallic and vegetable He found them on and about a large heap of kitchen poisons, including phosphorus. The stomach, duodenum, refuse (cooked meat, potatoes, green peas, uncooked potato and liver are also free from ptomaines, but in the contents of peelings, bread, cheese, paper, &c.) left uncovered by the the stomach I found a small quantity of toxic ptomaine troops. One of the older ewes, lying near the refuse heap, which was present in too small quantity to identify." was very ill and died a few minutes afterwards. Seven The cases were attributed by some to the effects of others of the older ewes were ill and five of them died before marching in the sun, by others to influenza, to mild yellow evening ; two took three days to recover. The farmer fever (with which no connexion could be established), to describes them as "bellies much distended, in great pain, Weil’s disease (of which little is known), and to food-poison- back hunched up, loss of power in hind limbs, no diarrhoea, ing. The water-supply and barracks were excellent and above vomiting, or nasal discharge." These sheep (two-year-olds) suspicion. The cases, even when the majority were confined had been born and bred on the farm and in these fields. The to one regiment, were scattered throughout different com- pasturage was clean and sound and devoid of poisonous panies and barrack rooms, so that no direct infection plants, &c., while no similar cases had been known on this appeared to be present. Everything seemed to point to the or on neighbouring farms. No sheep were affected after the rubbish had been covered. One of us accompanied Veterinary cause having been from something swallowed, and the prolonged pyrexia, variable incubation period, and gradually Major Moore (Professor in the Army Veterinary School) some increasing severity pointed to the action of some toxin- ten days later to the farm. We were shown the stomach of the producing micro-organism alive in the alimentary canal and first sheep which had died and we exhumed and examined two other sheep. The two latter had been fat and well probably not invading the tissues. With three exceptions the cases all occurred in one brigade nourished. Their stomachs showed signs of extremely acute (and inflammation?) and this was also present in (especially in one regiment) of 3474 soldiers out of a large congestion the of the small intestines; they had evidently and women and of 3000 portions 550 upper officers, 17,000 soldiers, garrison been much distended and seem to and the women children children. The officers during life. The livers were bile-stained have escaped entirely. The cases were admitted in four and were stated by Professor Moore to be enlarged. The batches as follows :kidneys were congested, inflamed, and disorganised. The other organs were normal. All three stomachs contained a large feed of young and old grass with a few bits of lemon, green-peas, onions and potato peelings, and a quantity of cheese (probably one and a half ounces in each). Specimens of this cheese were forwarded to Dr. Luff who reports: I I I found tyrotoxicon present in fairly large quantity. One milligramme of this tyrotoxicon injected into a rat killed it in three hours. The symptoms from which the soldiers suffered are quite compatible with these cases being due to

tyrotoxicon poisoning." Though tyrotoxicon is a fairly definite product the microorganism or group of micro-organisms which produce it are still an indefinite quantity, nor were we able in the limited time at our disposal to cultivate any organism of an unusual or pathogenic character. The clinical symptoms described by Professor Victor Vaughan and others1 have much in comwith those we have described. Were the cases confined to those persons who ate the particular cheese issued between August 24th and 31st there would be very strong presumptive evidence in favour of tyrotoxicon poison, but need to be connected with the a certain few cases common cause, which so far we have been unable to do. Each cheese weighed about 40 pounds and would supply about half a regiment. We are informed that they were cut up by the regiments with their own knives and no connexion mon

1 Seventh International Congress of Hygiene and Demography, 1891; Twentieth Century Practice, vol. xiii. ; Transactions of the Association of American Physiologists, Philadelphia, 1896, vol. xi. ; Anderson in the Inter-Colonial Medical Journal, Melbourne, 1898, vol. iii., p. 557; Wesener and Rossman in the Philadelphia Medical Journal, 1898, vol. i., p. 1119 ; and several German papers.

DR. R. HINGSTON FOX& DR. E. A. LERiTIT’1’E : INFECTIVE ENDOCARDITIS.

of knife, wrapper, butter,

of

1225

or milk could be made with other temperature extended much below normal in the latter The regiments of the lst Brigade were all close five days of life. The patient took food well throughout, but to one another in camp when most of the cases occurred and became wasted and anasmic. At the necropsy the heart was found to be much enlarged from August 24th only some four or five had not heen present in that camp. Though the cheese doubtless killed and the left ventricle was distended and filled with firm dark the sheep, more evidence is required to definitely settle the clot. The aortic valves were distorted and covered at their cause of the disease amongst the men. Having dealt with edges and bases by abundant granulations and there were all other articles of food about which we could obtain some granulations also on the auricular surfaces of the information and as we are both under orders to proceed mitral valves. The pericardium contained about four ounces shortly on active service to South Africa, we publish these of turbid bloody fluid containing flakes. The right pleura particulars with a hope that some of the readers of was more or less adherent throughout, especially to the THE LANCET may be able to throw further light on the diaphragm, and the left pleural cavity contained some fluid. Both lungs were gorged with blood, with signs of recent subject. Aldershot. pneumonia at the bases. There was some cicatrisation at both apices, including at the right apex calcareous deposit. The peritoneal cavity contained fluid. The liver and spleen were The kidneys were also large, the capsule splitting A CASE OF INFECTIVE ENDOCARDITIS enlarged. into two layers, of which the inner was adherent ; the cortex TREATED BY ANTI-STREPTOCOCCIC was pale and cloudy, the pyramids were dark, and many little red crystals of uric acid lay in the calices. There were no cysts or haemorrhages. The lumbar inter-vertebral discs DEATH. appeared to be healthy. No sign of suppuration was found BY R. HINGSTON FOX, M.D. BRUX., M.R.C.P. LOND., anywhere in the body. The treatment pursued was in part general and symptoAND matic, but the following points are of interest. It was E. AUGUSTUS LERMITTE, M B., B.S. DURH., strongly suspected that a suppurative lesion was present, and L.R.C.P. LOND., M.R.C.S.ENG., on April 9th the patient was thoroughly examined under an anaesthetic and the needle was inserted in several parts of the A MAN, aged 39 years, consulted Dr. Hingston Fox on loins and back, but no pus was fourd. Quinine was given for about, two weeks in three-grain or four-grain doses, or two Jan. 4th, 1899, for pain in the lumbar spine, with tingling three times a day, but it was wholly without effect grains in the legs and feet after exertion. The patient was a on the temperature. Sodium salicylate and alkalies seemed delicate-looking man, of anxious temperament, and had to reduce it sometimes. Arsenic was also used for some suffered from influenza with rheumatic symptoms a year weeks Anti-streptococcic serum from the Jenner Institute through Messrs. Allen and Hanburys and used previously. No history of exposure to sewer gas or other was obtainedfrom assiduously April 4th to llth. Fifteen doses in all septic conditions could be made out. His father died at 51 were injected beneath the skin of the abdomen or arm, years of age from carbuncle and his mother died at the age of generally of 10 cubic centimetres each, and amounting to a 76 years, but she had had delicate lungs in early life. There total of 149 cubic centimetres. The local irritation was conwas much tenderness over the whole lumbar spine, the kneesiderable and the patient disliked the injections ; evenjerks were active, and there was some ankle clonus on the tually copious erythematous lichen developed over much left side. The pain was lessened by rest, but it did not pass of the abdomen and the arm, as well as bosses of The temperaaway, and as the tenderness on pressure continued and there erythema at the site of the injections. was a slight deviation of the lower part of the lumbar spine ture, at that time ranging between 100° and 103°, to the left, it was thought on Feb. 9th that caries of the was in no way lowered, perhaps it was a little raised, spine was impending. The urine contained albumin, at first under their use, and he was unusually drowsy There was no a trace only, but increasing week by week, with excess of remission of any symptom. Nuclein was then tried from acidity, much deposit of urates, many squamous, mucous, the 12th to the 16th, 11 hypodermic injections being used, at and renal cells, and a few small casts. On one occasion first of from 20 minims to 30 minims of an old 1 per cent. a good many tufts of blood-vessels were found in the solution made by Messrs. Burroughs and Wellcome and with sediment, urinary capsules apparently containing later 16 minims of a new solution of the same strength cells. A small rough systolic bruit was heard over the prepared on purpose for this case by the same firm. The aortic orifice on Feb. 9th. The patient was confined to injections caused pain for a minute or two, the liquid his bed and couch from about Feb. 10th and the actual evidently irritating the tissues, and a very itchy rash came out cautery was applied near the spine on four occasions with over the abdomen and the back. The temperature remained the result that the spinal pain entirely subsided. Remittent high and no good effect whatever could be observed. The pyrexia (from about 99° F. to 101° or 1020) was observed from inhalation of oxygen was used during the latter weeks from his first confinement to bed and continued thenceforth. The time to time and the pulse-rate was quieted for awhile Small doses of antifebrin urine continued to be albuminous and loaded with urates and thereby-e g., from 130 to 112 uric acid, the latter sometimes in a copious sediment. Pain were also given during two days. On April 19th and 29th and swelling, apparently brief inflammatory embolisms only Dr. Lermitte applied an eclectic German oil, apparently conlasting a few hours or a day or two, appeared during the taining croton oil or some similar drug. The chest and abdolatter half of March in various locations-the right wrist, the men were first covered with rows of fine multiple punctures left cheek, and the left testicle. The temperature rose higher by a scarificator and the oil was painted over them, a thick in the last week of March and from that time pursued an wool wrapping being immediately applied and kept closely in irregular, fluctuating course, seldom falling below 100° in the apposition. In the course of two or three days a crop of morning and generally reaching 102° or 103° in the evening. innumerable small pustules had developed, and these in There were frequent sweats but no rigors. Meanwhile the another day or two dried up and the scabs could be brushed heart became gradually dilated and double aortic and systolic away. In the meantime the patient was very thoroughly mitral bruits developed. Staphylococci. probably pyogenes fed. The treatment was borne better than might be supalbus, were found in the blood on April 5th, butno strepto- posed and gave very little trouble. Under the first applicocci. The staphylococcus pyogenes aureus was obtained from cation ti.e temperature steadily declined for four days, the pustules on the 25th. Dr. Lermitte took charge of the case minima and maxima being as follows : April 19th, 100 4°. on April 6th, Dr. Fox continuing to see the patient in 103° ; 20th, 99 8°. 101 8°; 21st, 99°, 101°; 22nd, 99°, 100’4°; consultation at intervals. Signs appeared of much effusion and 23rd, 9 2°, 100°. The pulse dropped from 120 to about into, the peritoneal and pericardial cavities and some into 90, the tongue cleaned, the urine increased in quantity, and the pleural cavities. There were varying evidences of the general condition of the patient was easier. After the pneumonia and pleurisy at the bases of the lungs and fifth day the conditions all relapsed, the temperature reachduring the last month of life of hypostatic, congestion, also ing 103 6° on the 25th and the pulse being 120, and no further some aphthous stomatitis. The liver and spleen were good effect could be traced. The second application was enlarged and there were pains in the jaws, shoulders, and made at a late period when the heart was obviously failing other joints. The patient died on May 10th from slow heart and no distinct benefit was observed to follow it. failure with attacks, shortly before the end, of pain in the remarks by Dr. HINGSTON Fox.-The origin of the specific heart region and in the back of the thorax. The morning fall infection in this case-one of infective endocarditis of the T 2

regiments.

SERUM, NUCLEIN, &C.;