A fresh specimen of the muco-purulent stool of bacillary dysentery shows, in addition to pus cells, numerous large, phagocytic cells, which may show vacuolation and strikingly resemble amoebae. Such cells never show motility but, under conditions of lowered temperature of specimen or from prolonged standing and beginning disintegration, the amoebae too fail to show motility. If mounted in Gram’s iodine solution these large cells show a much larger nucleus than that of amoebae and take the yellow staining of iodine more intensely. The best method, however, is to make a smear, fix it by heat and stain by Gram’s method or with Loeffler’s blue or dilute carbol fuchsin. These confusing cells stain easily and perfectly and in the Gram specimen we note the Gram-negative bacilli in the cytoplasm. Giemsa’s stain, with methyl alcohol fixation, or the usual Wright or Leishman technique answer equally well. On the other hand it is rather difficult to obtain satisfactorily stained amoebae in this way, it usually being necessary to fix moist thin smears of the stool with some bichloride fixative, as Zenker’s fluid, and then carry out the staining with haematoxylin.
The Stained Smear.—The presence of pus cells as well as endothelial cells in a stained smear of material from a bacillary dysentery stool is of value in differentiating from an amoebic stool smear in which pus cells are rarely seen. The amoebic dysentery smear gives more the picture of granular débris.
We should always examine a stool as soon after it is passed as possible.
If the microscopical examination indicates a bacillary infection we should take a small mass of the stool, wash it in sterile water and then drop it in a tube of sterile bouillon or salt solution. After emulsifying in this tube of bouillon we take up 2 or 3 loopfuls of the emulsion and deposit them on a poured plate, later smearing out with a glass rod, either by successive parallel strokes or by revolving the plate while smearing the surface with the glass rod. It is in the first two or three days of an attack of acute dysentery that we obtain the best cultural results, often noting a pure culture of dysentery bacilli from proper material taken at the onset. Manson-Bahr states that he has never recovered true dysentery bacilli from a purely faecal stool. Even faecal contamination of the mucoid mass makes it difficult to recover the organism. Dysentery bacilli rapidly die out if the stool is acid so that it has been recommended to make the stool strongly alkaline where it has to be sent to a laboratory from a distance.
It has seemed to me that litmus lactose agar gives results more surely than the more restraining faeces-plating media. Still I generally use Endo’s fuchsin agar because it is always at hand for typhoid or paratyphoid culturing and gives good results. The dysentery bacillus colonies on this medium are like those of typhoid—grayish white. In England they prefer MacConkey’s neutral red bile salt agar while others use the Conradi-Drigalski medium. We are now using the Teague medium, which is taken up in the chapter on Faeces. On all these media the colonies resemble those of typhoid and the differentiation is most easily made by examining for motility. At the same time one not infrequently finds lack of motility in bacilli from colonies just isolated on Endo’s medium which later on in subculture show motility and are found to belong to the typhoid or paratyphoid group. For the sure determination of dysentery bacilli or for differentiating the Flexner and Shiga strains one should carry out agglutination tests.
The isolation of dysentery bacilli from chronic cases or from convalescents is more difficult as a rule and agglutination tests may be more practical. A trouble is that an agglutinating effect may be connected with a prior infection.
Although some observers have noted the appearance of agglutinins in the serum of cases of acute bacillary dysentery within three or four days from the onset of the disease, yet it is usual not to obtain agglutination with the patient’s serum before the tenth day. With the Shiga strains agglutinating power in 1 to 50 is usually accepted as evidence of specificity but for Flexner strains we generally have a higher titre so that a dilution of 1 to 150 should be required for the test.
Ritchie has recently tested the sera of 792 normal persons and found that 30% of these individuals agglutinated Shiga bacilli in 1 to 32, while with Flexner strains 41% agglutinated in 1 to 64 and 30% in 1 to 128. For comparison Ritchie’s results with typhoid showed that only 6% agglutinated such bacilli in 1 to 16. There is some evidence that typhoid vaccination increases the agglutinating power of the serum against dysentery organisms. These findings are remarkable, as the usual advice is to consider an agglutination of 1 to 30 as fairly specific for Shiga infections and 1 to 100 for Flexner ones.
Willmore and Savage tried heating serum to 56°C. for thirty minutes, but found that such a procedure was of no practical value with dysentery, thus differing from Malta fever serum where such a procedure is of value in destroying coagglutinins and thus increasing the specific action. The work of Ohno would indicate that we should trust to the acid-producing effect on mannite for differentiating Flexner and Shiga strains rather than on agglutination because it was found that agglutinins for an acid strain were not always more specific for such strains than for nonacid ones.
At the same time it is the rule for a Flexner type bacillus to show specificity for its serum and the Shiga type for the serum of the more toxic, nonacid-fast Shiga strain cases. The statement of Willmore and Savage that the differentiation of bacillary dysentery infections is a refinement of technique seems a proper view because with a polyvalent serum for treatment one only needs to know that the case is one of bacillary dysentery for proper treatment. Of course with a monovalent serum, effective only for the Shiga bacillus, one would have to determine whether the organism producing the dysentery was of that strain.