NOTES AS
ON
THE
SEEN
IN
ENTERIC AN
GROUP
ISOLATION
OF
DISEASES
HOSPITAL
IN
FRANCE. BY
J.
M. Fortescue-Brickdale, M.A., M.D., M.R.C.P., Captain
R.A.M.C.
(T.).
paper I propose describing first the general arrangements of the hospital to which I was attached and In
this
the
measures
spread
of
taken
infection,
to
isolate
and
in
patients the
and
second
prevent the part to give
my own impressions as to the clinical features of the enteric group of cases, more especially with reference to
Paratyphoid B. The hospital
consisted
primarily
of
eight huts,
each
73
NOTES ON THE ENTERIC GROUP OF DISEASES.
by 15 feet, arranged in two sets on either side of a. central path with their ends opposite to each other. Being somewhat narrow, only one row of beds could be placed in them, though a few beds could be put lengthwise against the opposite wall. Besides these huts we had eight Armstrong Huts," made of canvas, holding two or three beds each ; they are very nice in the summer when the side can be opened and an awning fitted to it, but we found them rather chilly 120 feet
"
and dark in the winter.
tents,
and later
on
niarquees, which the
original
the
were
huts
We had also
hospital put up in
was a
number of bell
field below that
hospital which
on
erected.
were
The various administrative of
a
extended into
buildings
constructed
were
placed on two adjacent sides of the square block of buildings formed by the wards. The first thing found necessary was to divide the long huts into two parts, in order to isolate patients suffering and wood, and
corrugated iron
were
from different diseases.
We allotted wards
various infections
thought they
to be
required
as we
; but
we soon
or
half wards to
would be most
found that the
likely greater part of
given up to enteric, and that the arrangement of the remaining part would constantly our
wards would have to be
require
modification
according
mtended for officers, and
prevalence of one or Armstrong Huts were during the summer largely
to the
other of the infectious diseases. were
used for their accommodation,
generally kept of which to
men.
in
one
ward and
we
for infections, such
had
During
only
a
few
but as
cases at a
some
of them
scarlet fever
time, and
built with
separate
kitchens, bathroom,
used for observation
in
rooms,
the
cases,
an
were
measles, allotted
were
spring holding two
etc., to itself.
or
were
the winter officers with enteric
of the half wards, and
was
The
placed
officers'
beds each,
The bell tents
but most of these
were
were
taken
down in the winter, the Armstrong Huts being used instead.
CAPTAIN
74
J. M. FORTESCUE-BRICKDALE
The two main the erection of
improvements made to the wards were small sanitary annexe (6 feet by 6 feet) at
a
each end of the wards of
a
small sister's
with
feet),
long huts,
and the construction inside the
duty
room
and
a
scullery (8
feet
by
passage between them in the centre of the
a
wards where the
partition came. reception-room and a large kitchen and stove service of the Armstrong Huts were also built during
A wooden for the
the autumn.
regulations and arrangements for preventing spread of diseases from the hospital
The
infection and the
briefly
as
out from the
patients and orderlies hospital kitchen. The
not allowed to have any meals
was
cooked and sent
sisters and orderlies or
food themselves in
the wards, but took all their meals in their The orderlies
messes.
were
follows.
All food for
were
cross
on
duty
own
in the wards
respective hospital
wore
blue, with their uniform caps, and both sisters and orderlies wore
The orderlies
overalls.
changed
their clothes when
coming on and off duty in one of the sanitary annexes which kept for the purpose. (The other sanitary annexe was used for keeping urine bottles and bed-pans.) Orderlies were not allowed to smoke on duty or to carry cigarettes was
behind their
ears.
The kitchen had three storerooms, where meat, and milk
kept
were
main kitchen, and was
kept
in
a
;
they
were
were
fly-proof cupboard with Each patient had his
spoon, and feeder, which his bed.
disposal
patients by
the
was as
orderly
were
numbered and
to the
Bed-pans
Bread
gauze sides in own
of excreta and water used
follows.
vegetables
shut off from the
covered in with muslin.
the steward's store.
The
partly
as soon as
plate, bowl,
belonged for
a
washing
were
taken
cloth.
The
used
destructor, covered by
to
75
NOTES ON THE ENTERIC GROUP OF DISEASES.
contents
were
destructor. who
mixed with sawdust and burnt in Horsefall
The
placed
bed-pan
was
left with the
it in cresol till disinfected.
to the ward.
Urine
was
It
sanitary orderly,
was
carried in the bottle
then returned as soon as
it
building, and poured into a large placed in a tub of cresol in a small adjoining room. The orderly carried back a clean bottle from the shelf in the same room. The urine after boiling was run by a pipe into a large soak pit. Water used for in the same was boiled also way before Washing patients running into the soak pit. On the arrival of an ambulance with a suspected enteric case, the patient was taken on his stretcher to the reception hut, seen by the O.M.O., and his particulars taken by the N.C.O. on duty. The ambulance was sprayed with formalin, and a new stretcher and blankets given to the driver. The O.M.O. then sent the patient was
passed
boiler,
to the
same
and the bottle
to the
reception ward, the stretcher was sprayed, and the blankets and patient's kit taken to the steam disinfector. At
night
necessary
the O.M.O. attended
to
the
patient
and if
charge of saw the patient at once,
called the M.O. who would have
patient. During the day the M.O. took a specimen of blood for the ?f the next
twenty-four
cither
clinical
on
or
hours it
and
In the
course
usually possible
to say
pathologist. was
the
pathological grounds
whether
the
patient clearly had an enteric infection, or whether he was a doubtful case who would require further watching and
observation was
then
before
a
definite
transferred
observation ward
either
diagnosis to
an
could be made. enteric
ward
or
He an
preliminary classification eventually again transferred to his proper place in the hospital. Those against whom no evidence of enteric infection could be brought either by the clinician or the pathologist found their way eventually into a special turned
; if the
out to be wrong he was
Ward reserved for
"
wash-outs," and
were
labelled influenza
76
CAPTAIN
J. M.
FORTESCUE-BRICKDALE
myalgia or P.U.O. according to circumstances. patients, when well, were sent to their base depots or or
convalescent
the discretion
at
depot
included
of the M.O. at
-least
These to the
The blood
pathological investigations culture, three agglutination tests against Typhoid, Paratyphoid A. and Paratyphoid B., and three examinations of the faeces and urine for organisms. When fit to walk about and take
light exercise,
and notes of the certificates
signed by
all enterics were evacuated to
typed
measures were
two
orderlies who
had
some cases
remember
only
on
England,
the back of their transfer
the C.O.
These
only we
case
one
I can remember very successful. contracted enteric, and though
of double infection among patients, I can in which we certainly thought that the
one
second infection
might have been acquired in the hospital. supervision of the orderlies was necessary : lectures were arranged for-them and given by the M.O.'s which dealt with infectious diseases and sanitation. If they were caught disobeying rules, the matter was reported to the C.O., and punishment inflicted when it seemed necessary. The "Enteric Group" is taken to include Typhoid, Para'' typhoid A. and Paratyphoid B. and the term enteric Of course, constant
"
is not used as synonymous with typhoid, but as designating the group. In making returns, if the bacteriological evidence was not sufficient to identify a case, but clinically the patient
appeared to have one to diagnose it as "
of the three diseases, Enteric
Group."
which the three diseases occurred
were
we were
instructed
proportions in roughly 10 per cent. The
4 per cent. Paratyphoid A., and 81 per cent. Paratyphoid B., the remaining 5 per cent, being Enteric
Typhoid,
"
Group." of course,
impossible to diagnose clinically the presence of a particular causal organism in any disease. This can only be done by means of bacteriological investigation.. It
is,
77
NOTES ON THE ENTERIC GROUP OF DISEASES.
But just
as
diphtheria
can
other forms of tonsillitis in
ally possible
to
give
be in a
practice distinguished
number of cases,
so
from
it is occasion-
an
accurate guess as to which of the
enteric groups a patient belongs. But, as a rule, this can be done only when the patient has been under observation for some
time, and the general features and
have been noted. between typhoid
Paratyphoid present
It is
more
and
the
A. and B.,
diagnosis always diagnosis is accepted
of the attack
distinguish clinically paratyphoids than between to
possible in
though
features.
suggestive
course
rests with the
some cases
the former
Practically, however, the bacteriologist, and no clinical "
other than that of
Enteric
Group."
I propose now to set down some rough notes on the symptoms and course of the paratyphoid fevers as I saw them. Onset.?The mode of onset appears to have some relation to the severity of the attack. Three types may be i.
distinguished.
Those in which the onset is
quite abrupt ; patient goes to bed feeling quite well, and wakes up next morning unable to go on duty. In the next group there is a week or less of prodromal symptoms, not very the
serious
or
definite in character.
In the third these
prodromal
symptoms are noted for a longer time, and the onset is more gradual. A larger proportion of severe cases were found to follow
on
proportion
this third
type of onset, type of onset.
Initial symptoms the
most
and
frequent
in number, but
are many is headache.
are not uncommon,
Diarrhoea and
and sometimes
pain
are
less
common.
nasal catarrh,
conjunctivitis
occasionally symptom, but
seen.
are
initial
is not
by far shivering
in the back and
abdomen; vomiting cough laryngitis of mild type, herpes and
frequent
the smallest
to follow the first
Fainting,
labialis and
Epistaxis uncommon
is not
a
at some
period in the attack. 2.
Pyrexia.?In
our cases
of
Paratyphoid
B.
we
found
CAPTAIN
78
J. M.
FORTESCUE-BRICKDALE
about 80 per cent, with ten days' fever or more, and 20 per In analysing the former cent, with under ten days' fever. group I
was
able, I thought,
types (a) Simple
distinguish
continued fever, often with
very characteristic Intermittent type, the intermissions
remission, but with
(b)
to
no
the
following
tendency
a
to
curve.
usually occurring
towards the end of the attack, but sometimes at the beginning, or more or
less
throughout.
Nearly
half the
cases
showed
type of fever, which is illustrated by Chart 1. (c) Undulant type. In half these cases the notes showed that there were more or less well-marked pulmonary symptoms, but beyond that the type of fever could not be correlated to any other features in the attack. (Chart 2). (d) Low, irregular fever. In this type, often after a few days' high fever, the temperature fell to normal or subnormal in the morning, but rose.to 99 per cent, or 100 per cent. F. this
Chart i. i. Intermittent type Intermittent
of pyrexia. Paratyphoid B. isolated from Agglutinations positive to Paratyphoid B.
urine 18th iSth day.
THE ON NOTES DISEASES. OF GROUP ENTERIC B. isolated from fcsces Paratyphoid B,
on
8th
day of disease.
Agglutinations positive
to
paratyphoid
B.
79
Chart 2.
Undulant type of fever.
80
CAPTAIN
in the -was
evening,
often In
J. M.
FORTESCUE-BRICKDALE
and sometimes
a
little
higher.
The attack
prolonged.
certain number of cases, a week or so after the (e) temperature had fallen there was a sudden rise of temperature lasting about twenty-four hours, usually accompanied by headache or general pains. These rises were sometimes repeated several times. We often found the spleen tender, but could not detect any tenderness over the gall bladder, which has been noted by other observers. The attacks are not serious, and the patient is generally well the next day. (Chart 3). 3. Fades and Constitutional Symptoms.?The patient's appearance is often quite without any diagnostic significance but in some cases he has a peculiar heavy, "bloated," coarse appearance, which is rather suggestive. The constitutional a
disturbance may be considerable, but on the whole in paratyphoid the patient is not so ill as in typhoid, having regard 12l l
ON
THE
SEEN
IN
ENTERIC AN
GROUP
ISOLATION
OF
DISEASES
HOSPITAL
IN
FRANCE. BY
J.
M. Fortescue-Brickdale, M.A., M.D., M.R.C.P., Captain
R.A.M.C.
(T.).
paper I propose describing first the general arrangements of the hospital to which I was attached and In
this
the
measures
spread
of
taken
infection,
to
isolate
and
in
patients the
and
second
prevent the part to give
my own impressions as to the clinical features of the enteric group of cases, more especially with reference to
Paratyphoid B. The hospital
consisted
primarily
of
eight huts,
each
73
NOTES ON THE ENTERIC GROUP OF DISEASES.
by 15 feet, arranged in two sets on either side of a. central path with their ends opposite to each other. Being somewhat narrow, only one row of beds could be placed in them, though a few beds could be put lengthwise against the opposite wall. Besides these huts we had eight Armstrong Huts," made of canvas, holding two or three beds each ; they are very nice in the summer when the side can be opened and an awning fitted to it, but we found them rather chilly 120 feet
"
and dark in the winter.
tents,
and later
on
niarquees, which the
original
the
were
huts
We had also
hospital put up in
was a
number of bell
field below that
hospital which
on
erected.
were
The various administrative of
a
extended into
buildings
constructed
were
placed on two adjacent sides of the square block of buildings formed by the wards. The first thing found necessary was to divide the long huts into two parts, in order to isolate patients suffering and wood, and
corrugated iron
were
from different diseases.
We allotted wards
various infections
thought they
to be
required
as we
; but
we soon
or
half wards to
would be most
found that the
likely greater part of
given up to enteric, and that the arrangement of the remaining part would constantly our
wards would have to be
require
modification
according
mtended for officers, and
prevalence of one or Armstrong Huts were during the summer largely
to the
other of the infectious diseases. were
used for their accommodation,
generally kept of which to
men.
in
one
ward and
we
for infections, such
had
During
only
a
few
but as
cases at a
some
of them
scarlet fever
time, and
built with
separate
kitchens, bathroom,
used for observation
in
rooms,
the
cases,
an
were
measles, allotted
were
spring holding two
etc., to itself.
or
were
the winter officers with enteric
of the half wards, and
was
The
placed
officers'
beds each,
The bell tents
but most of these
were
were
taken
down in the winter, the Armstrong Huts being used instead.
CAPTAIN
74
J. M. FORTESCUE-BRICKDALE
The two main the erection of
improvements made to the wards were small sanitary annexe (6 feet by 6 feet) at
a
each end of the wards of
a
small sister's
with
feet),
long huts,
and the construction inside the
duty
room
and
a
scullery (8
feet
by
passage between them in the centre of the
a
wards where the
partition came. reception-room and a large kitchen and stove service of the Armstrong Huts were also built during
A wooden for the
the autumn.
regulations and arrangements for preventing spread of diseases from the hospital
The
infection and the
briefly
as
out from the
patients and orderlies hospital kitchen. The
not allowed to have any meals
was
cooked and sent
sisters and orderlies or
food themselves in
the wards, but took all their meals in their The orderlies
messes.
were
follows.
All food for
were
cross
on
duty
own
in the wards
respective hospital
wore
blue, with their uniform caps, and both sisters and orderlies wore
The orderlies
overalls.
changed
their clothes when
coming on and off duty in one of the sanitary annexes which kept for the purpose. (The other sanitary annexe was used for keeping urine bottles and bed-pans.) Orderlies were not allowed to smoke on duty or to carry cigarettes was
behind their
ears.
The kitchen had three storerooms, where meat, and milk
kept
were
main kitchen, and was
kept
in
a
;
they
were
were
fly-proof cupboard with Each patient had his
spoon, and feeder, which his bed.
disposal
patients by
the
was as
orderly
were
numbered and
to the
Bed-pans
Bread
gauze sides in own
of excreta and water used
follows.
vegetables
shut off from the
covered in with muslin.
the steward's store.
The
partly
as soon as
plate, bowl,
belonged for
a
washing
were
taken
cloth.
The
used
destructor, covered by
to
75
NOTES ON THE ENTERIC GROUP OF DISEASES.
contents
were
destructor. who
mixed with sawdust and burnt in Horsefall
The
placed
bed-pan
was
left with the
it in cresol till disinfected.
to the ward.
Urine
was
It
sanitary orderly,
was
carried in the bottle
then returned as soon as
it
building, and poured into a large placed in a tub of cresol in a small adjoining room. The orderly carried back a clean bottle from the shelf in the same room. The urine after boiling was run by a pipe into a large soak pit. Water used for in the same was boiled also way before Washing patients running into the soak pit. On the arrival of an ambulance with a suspected enteric case, the patient was taken on his stretcher to the reception hut, seen by the O.M.O., and his particulars taken by the N.C.O. on duty. The ambulance was sprayed with formalin, and a new stretcher and blankets given to the driver. The O.M.O. then sent the patient was
passed
boiler,
to the
same
and the bottle
to the
reception ward, the stretcher was sprayed, and the blankets and patient's kit taken to the steam disinfector. At
night
necessary
the O.M.O. attended
to
the
patient
and if
charge of saw the patient at once,
called the M.O. who would have
patient. During the day the M.O. took a specimen of blood for the ?f the next
twenty-four
cither
clinical
on
or
hours it
and
In the
course
usually possible
to say
pathologist. was
the
pathological grounds
whether
the
patient clearly had an enteric infection, or whether he was a doubtful case who would require further watching and
observation was
then
before
a
definite
transferred
observation ward
either
diagnosis to
an
could be made. enteric
ward
or
He an
preliminary classification eventually again transferred to his proper place in the hospital. Those against whom no evidence of enteric infection could be brought either by the clinician or the pathologist found their way eventually into a special turned
; if the
out to be wrong he was
Ward reserved for
"
wash-outs," and
were
labelled influenza
76
CAPTAIN
J. M.
FORTESCUE-BRICKDALE
myalgia or P.U.O. according to circumstances. patients, when well, were sent to their base depots or or
convalescent
the discretion
at
depot
included
of the M.O. at
-least
These to the
The blood
pathological investigations culture, three agglutination tests against Typhoid, Paratyphoid A. and Paratyphoid B., and three examinations of the faeces and urine for organisms. When fit to walk about and take
light exercise,
and notes of the certificates
signed by
all enterics were evacuated to
typed
measures were
two
orderlies who
had
some cases
remember
only
on
England,
the back of their transfer
the C.O.
These
only we
case
one
I can remember very successful. contracted enteric, and though
of double infection among patients, I can in which we certainly thought that the
one
second infection
might have been acquired in the hospital. supervision of the orderlies was necessary : lectures were arranged for-them and given by the M.O.'s which dealt with infectious diseases and sanitation. If they were caught disobeying rules, the matter was reported to the C.O., and punishment inflicted when it seemed necessary. The "Enteric Group" is taken to include Typhoid, Para'' typhoid A. and Paratyphoid B. and the term enteric Of course, constant
"
is not used as synonymous with typhoid, but as designating the group. In making returns, if the bacteriological evidence was not sufficient to identify a case, but clinically the patient
appeared to have one to diagnose it as "
of the three diseases, Enteric
Group."
which the three diseases occurred
were
we were
instructed
proportions in roughly 10 per cent. The
4 per cent. Paratyphoid A., and 81 per cent. Paratyphoid B., the remaining 5 per cent, being Enteric
Typhoid,
"
Group." of course,
impossible to diagnose clinically the presence of a particular causal organism in any disease. This can only be done by means of bacteriological investigation.. It
is,
77
NOTES ON THE ENTERIC GROUP OF DISEASES.
But just
as
diphtheria
can
other forms of tonsillitis in
ally possible
to
give
be in a
practice distinguished
number of cases,
so
from
it is occasion-
an
accurate guess as to which of the
enteric groups a patient belongs. But, as a rule, this can be done only when the patient has been under observation for some
time, and the general features and
have been noted. between typhoid
Paratyphoid present
It is
more
and
the
A. and B.,
diagnosis always diagnosis is accepted
of the attack
distinguish clinically paratyphoids than between to
possible in
though
features.
suggestive
course
rests with the
some cases
the former
Practically, however, the bacteriologist, and no clinical "
other than that of
Enteric
Group."
I propose now to set down some rough notes on the symptoms and course of the paratyphoid fevers as I saw them. Onset.?The mode of onset appears to have some relation to the severity of the attack. Three types may be i.
distinguished.
Those in which the onset is
quite abrupt ; patient goes to bed feeling quite well, and wakes up next morning unable to go on duty. In the next group there is a week or less of prodromal symptoms, not very the
serious
or
definite in character.
In the third these
prodromal
symptoms are noted for a longer time, and the onset is more gradual. A larger proportion of severe cases were found to follow
on
proportion
this third
type of onset, type of onset.
Initial symptoms the
most
and
frequent
in number, but
are many is headache.
are not uncommon,
Diarrhoea and
and sometimes
pain
are
less
common.
nasal catarrh,
conjunctivitis
occasionally symptom, but
seen.
are
initial
is not
by far shivering
in the back and
abdomen; vomiting cough laryngitis of mild type, herpes and
frequent
the smallest
to follow the first
Fainting,
labialis and
Epistaxis uncommon
is not
a
at some
period in the attack. 2.
Pyrexia.?In
our cases
of
Paratyphoid
B.
we
found
CAPTAIN
78
J. M.
FORTESCUE-BRICKDALE
about 80 per cent, with ten days' fever or more, and 20 per In analysing the former cent, with under ten days' fever. group I
was
able, I thought,
types (a) Simple
distinguish
continued fever, often with
very characteristic Intermittent type, the intermissions
remission, but with
(b)
to
no
the
following
tendency
a
to
curve.
usually occurring
towards the end of the attack, but sometimes at the beginning, or more or
less
throughout.
Nearly
half the
cases
showed
type of fever, which is illustrated by Chart 1. (c) Undulant type. In half these cases the notes showed that there were more or less well-marked pulmonary symptoms, but beyond that the type of fever could not be correlated to any other features in the attack. (Chart 2). (d) Low, irregular fever. In this type, often after a few days' high fever, the temperature fell to normal or subnormal in the morning, but rose.to 99 per cent, or 100 per cent. F. this
Chart i. i. Intermittent type Intermittent
of pyrexia. Paratyphoid B. isolated from Agglutinations positive to Paratyphoid B.
urine 18th iSth day.
THE ON NOTES DISEASES. OF GROUP ENTERIC B. isolated from fcsces Paratyphoid B,
on
8th
day of disease.
Agglutinations positive
to
paratyphoid
B.
79
Chart 2.
Undulant type of fever.
80
CAPTAIN
in the -was
evening,
often In
J. M.
FORTESCUE-BRICKDALE
and sometimes
a
little
higher.
The attack
prolonged.
certain number of cases, a week or so after the (e) temperature had fallen there was a sudden rise of temperature lasting about twenty-four hours, usually accompanied by headache or general pains. These rises were sometimes repeated several times. We often found the spleen tender, but could not detect any tenderness over the gall bladder, which has been noted by other observers. The attacks are not serious, and the patient is generally well the next day. (Chart 3). 3. Fades and Constitutional Symptoms.?The patient's appearance is often quite without any diagnostic significance but in some cases he has a peculiar heavy, "bloated," coarse appearance, which is rather suggestive. The constitutional a
disturbance may be considerable, but on the whole in paratyphoid the patient is not so ill as in typhoid, having regard 12l l
