Attention was first drawn to the fact that Salmonella organisms other than Salmonella typhosa were of importance as pathogenic organism in childhood in tropical regions by Jeliffe et al (1954) and by de Silva (1958). Because gastroenteritis was the most frequent clinical picture in Salmonellosis we asked for a culture of Shigellas and Salmonellas every time we sent a stoolspecimen to the laboratory. The disappointing result of the bacterial examination of Shigellas was mentioned in the preceding section. Only twice did people succeed in isolating a Salmonella strain from the stools out of the 63 specimen sent to the laboratory. The two Salmonella organisms which were isolated were S.para typhi A. and S. hirschfeldii ©. These two patients concerned suffered from enteritis. Once S. para typhy A was isolated from the bloodstream of a patient who suffered from a disease which was very similar to typhoid fever. Three times a Salmonella strain was isolated from the cerebrospinal fluid of patients suffering from purulent meningitis. These strains were of the type S. heidelberg, S. typhi murium and S.Javiana.
In the period 1925-1929 Bosch investigated an epidemic of a disease caused by S.suipestifer at Kisaran in Sumatera. This epidemic developed gradually and lasted several years among the Javanese labourers, who worked on the plantations in that region. In this period of 5 years 203 patients were observed in the region of Kisaran.
As many patients were toddlers who had never visited the rubber-plantations and as the disease especially occurred among adults who had just arrived it was supposed that the disease was imported from Java. The clinical picture was similar to Typhoid fever. The S.suipestifer was isolated from the bloodstream, urine and feces. Symptoms of enteritis were not observed.
The occurrence of pathogenic Salmonella strains has been known since 1935 through the investigations of Erber and de Moor. In the publications of the pre-war period Erber and de Moor mentioned 12 different strains of Salmonellas which they isolated from the blood, feces and pus of Indonesian children, sent to their laboratory.
These twelve were: B-group types: S. schottmülleri, S. typhi murium, S. stanley, S. derby. C-group types: S. hirschfeldii, S. cholerae suis, S. newport. S. thompson. D-group types: S. enteritides, S. dublin. E-group types: S. meleagridis, S. lexington.
The clinical picture of the diseases these children suffered from was similar to that of typhoid fever, and gastroenteritis. Sometimes the organisms were isolated from pus taken from umbilical abces, empyema and coxitis.
From the publication of Erber and de Moor (1955). it appeared that the number of pathogenic Salmonellas strains, isolated and identified in indonesia, had increased to 30, including the Salmonella typhosa.
In the children’s wards at Jogjakarta the diseases caused by pathogenic Salmonellas were only a few of the diseases observed.
We suppose that a special investigation with a laboratory special equiped for this Salmonella isolating would give more and extensive data. In the publication of Ismangoen (1957) he described an infant suffering from diarrhoea in the first weeks of life. In the stools of this patient besides a pathogenic strain of E.coli also a Salmonella could be demonstrated, viz. S.worthington.
In the children’s ward of Bethesda hospital three patients suffering from meningitis purulenta caused by a Salmonella were admitted in the period July 1, 1954 till July 1, 1958. In the literature about this subject it appeared that Salmonella-meningitis in childhood is rare. In Indonesia two cases of Salmonella-meningitis are mentioned by Erber (1940). In these cases the S. typhimurium was isolated from the cerebrospinal fluid. The age of these patients was not mentioned by Erber. In 1930 Valk described a case of purulant meningitis by S.schottmulleri in a boy of 5 days old in Semarang. All other cases of Salmonellosis published in Indonesian literature do not concern meningitis patients.
Because Salmonella-meningitis is so rare in Indonesia we like to mention three short case histories of these patients, who suffered of meningitis purulenta caused by S.typhimurium (var.Copenhagen); S. heidelberg; and S. Javiana.
Case history I:
Agoes Soehardono, aboy, two years old, was admitted on September 27, 1955. For 4 days he had suffered from fever, diarrhoea and vomiting. Without treatment the fever disappeared in three days. During admission no diarrhoea could be observed in this patient. Malaria, pneumonia, typhoid fever, cystitis and tuberculosis could be excluded in the examinations made during his stay in hospital. From the 7th till the 15th day in hospital he suffered from fever again, but the cause could not be found. After 3 weeks in hospital the child was discharged in a good condition, and with a good appetite. Nine days after discharge the parents took the child to hospital again because the boy suffered from a paralysis of the left arm and leg. The cerebral spinal fluid was examined and appeared to be normal (Nonne- and Pandy-Test; cell count, protein, glucose, and NaCI). On the seventh day after re-admission the child got fever and convulsions. He was a little dozy and seven days after the first lumbar puncture we repeated this. The cerebrospinal fluid now appeared turbid. Pandy- and Nonne-test positive; cells 14,800 per mm3; while S.typhimurium could be isolated from the C.S.fluid. After preliminary treatment with penicillin and streptomycin, we changed to chloromycetin after receiving the information of the laboratory that the isolated organism was a Salmonella. After 13 days of chloromycetin treatment we stopped. There was a good response to this treatment and on the 25th day after re-admission the cerebrospinal fluid had very much improved (Nonne-and pandy still positive; cells 300 per mm3; protein in 800 mg per 100 cc; glucose 1.08 per 100 cc) and the boy had for several days been without fever. In the next few days the general condition of the child worsened and he died on the 29th day after re-admission.
Case history II:
Djoko Soetritijahto, a boy, three months old, was admitted because of fever and convulsion. The child was admitted on the same day. The liver and spleen appeared to be enlarged. The C.S. Fluid was purulent. The examination in the laboratory was as follows: Nonne- and Pandy test positive, cells 10,000 per mm3; glucose 20 mg per 100 cc; protein 362 mg per 100 cc. From the C.S.fluid Salmonella heidelberg of the B-group could be isolated. 17 days before admission this patient had been examined in the out-patients department because he had suffered from diarrhoea for 5 days. In spite of the advice to come for daily control the mother waited 17 days and returned to the hospital after the first convulsion occurred. The child died on the day of admission.
Case history III:
Warsita, a girl of 70 days, was taken to hospital because she suffered from an ulcus corneae of the left eye and signs of xerophthalmia on the right eye. Bodyweight was 3,050 grams. She also had a fever. The liver and spleen appeared to be enlarged. On the second day after admission the fever disappeared but returned on the fifth day after admission. On the fifth day also a convulsion occurred. A lumbur puncture was done and it appeared that the C.S. Fluid was turbid. The Nonne- and Pandy-tests were positive, the cell count was 800 cells per mm3, while the glucose and protein percentages were 40 mg and 440 mg per 100 cc respectively. From the C.S. Fluid the Salmonella javiana of the D-group could be isolated. After five days of treatment with penicilline and streptomycin the therapy was changed to chloromycetin 200 mg per day for 13 days. After this course of treatment the C.S. Fluid had not improved and it was possible to isolate the same Salmonella strain from the C.S. Fluid. The treatment was changed and the child got 200 mg chloromycetin intramuscularly and 50 mg intravenously for nine days. After these nine days it appeared that the C.S. Fluid has much improved and the treatment was stopped. During the 4½ months after stopping the treatment we regularly checked the C.S.fluid and it appeared that this became rapidly normal again.
The Salmonella Javiana was sent to the Statens Serum Institut and identified as Salmonella Javiana with an antigen structure (I) IX,1. z.23-1.5.
In 1940 this Salmonella type was first identified in Indonesia by Erber in a case of enteritis and after 1940 this type of Salmonella was sporadically isolated from the bloodstream and mesentery lymphnodes of healthy buffaloes and pigs (Erber, 1954).
The patients who died of Salmonellosis were registered in table VII-7 in the section: All other causes of death, except patients suffering from paratyphus A who were registered in the section infectious diseases.